2016_1109 ! �
IRRIGATION �.�C DOMESTIC FIRELINE /��,
The following form must be completed for each assembly tested. A signed and dated original
� ���.
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. #0570040
(Customer)
MAILING ADDRESS: �.�Cp � �- �CJ�-�...� ���.�t � `�
CONTACT PERSON/PHONE: ���._l - C..�v 7��
LOCATION OF SERVICE: '�'•
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
--Reduced Pressure Principle �IReduced Pressure Principle-Detector
i yHtSuble Check Valve �Double Check-Detector
�7PressureVacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker
Manufacturer t.��`��'"� Model Number � i � Size�
Located At �--�'�� Serial Number �i '� �� � � ��
Is the assembly instal ed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valvef Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held at��psid Op ned a f Op�ed,a����� e
Initial Test Closed Tightl�'`` Closed Tight � 1 psi ,,� p i�.��-,.
___.....-.
Leaked' I Leaked'. I Did n o'�em�-�--- D'd no pen .1 Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight-� Closed Tight_-' psid psid psid
Test gauge used: Make/Model��;��c..t���a ;-f� C_ C.�-r-..� SN: ������'�---�'*
Date Tested for Accuracy: � '` �- �� 1 t,.
Remarks:
The above is certified to be true at the time of testing.
���`�� �` �� �
Firm Name i Address � '
A�-
r � �
Certified Tester(print) r..._ ��-�-�''� Certified Tester(signature)
Firm Phone# � - � �! � � � ``-4� Cert.Tester No. �� � Date � �� � ��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow�Customer Copy Pink-Tester's Copy