2016_1130 (2) IRRIGATION 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 I.D. #0570040
(Customer)
MAILING ADDRESS: z.� CJ . /a'�c�µ---
CONTACT PERSON/PHONE: c1�c� � �--s��--<�fi-
LOCATION OF SERVICE: ��,.�:R;e� �c�-��
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
I�Reduced Pressure Principle �Reduced Pressure Principle-Detector
1�oubleCheckValve ❑Double Check-Detector
�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
� i�
Manufacturer (,JC�"�S Model Number �C� Size �-
Located At /r�1'e r !l�k � � ��'n-%��e._(�c�l f-Serial Number ��%� � �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �-t S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at �--v psid Held at��-�-- psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight l� psid psid psid
Leaked❑ Leaked��.l Did not open �� Did not open �l 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 /� �/e ���`- ��C�/-'� SN: c�(��-Z-��'�
Date Tested for Accuracy: ��G�� ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name ..��.-,TC��-c-� ���� Firm A ddress ��.� �•-� �t�� �r c lc� � (3�
Certified Tester(print)������������ 1.�c;��,��Certified Tester(signature , , -����'�'
Firm Phone# b ��- �i z- �Z S� Cert.Tester No. �S�� ! Date ��� 3��' I�
* 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