2016_1206 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)
MA[LING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERV ICE: _ � � fl� �/4u d"��.�
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 Reduced Pressure Principle-Detector
�Double Check Valve Double Check-Detector
Pressure Vacuum Breaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer �r��7�/t/ � Model Number �-5 � Size �/`7�
Located At_C���v I �/�it�D Serial Number�} ���3 ��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � C 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�� � psid Held at�� Z psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight ?c' psid psid psid
Leaked� � Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight � Closed Tight psid sid
p psid
Test gauge used: Make/Model Co����Jc v �-i�',��r� %/� ,., SN:t�foU�-( / (��'� �
Date Tested for Accuracy: � ��ry �/ �,
Remarks:
The above is certified to be true at the time of testing.
Firm Name_ s /.� .��s2 Firm A ddres��vro� G��S�j/'� L i✓ s r�l/�SG /,(�
�YI/cif?�L (�'�'u�Z 6C.: � �
Certified Tester(pr�nt) Certified Tester(signatur�����/'��'� �ry�(
Firm Phone#%�� %�U- � ��3�-� Cert.Tester No.�S %!> Date�o� //
* 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