2016_0613 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: / L7 � t 10 ��
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
' iReduced Pressure Principle Reduced Pressure Principle-Detector
�'DoubleCheckValve - Double Check-Detector
' 'PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer GurC /�.S Model Number .�$� Size �/
Located At �=Qv�v� ►>�42A Serial Number/9',S'SS���
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ► 1�S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a��3 psid Held a�' � psid Opened at Opened at Held at
Initial Test Closed Tight�" Closed Tight ,J1� psid psid psid
Leaked Lcaked Did not open Did not open Lcaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight ' Closed Tight psid psid psid
Test gauge used: Make/Model Com,bl�'/}tv �/d-m�ov J fi�/ SNf� �i(7 Lf / �v �J 7
Date Tested for Accuracy: �f / �/5�
Remarks:
The above is certified to be true at the time of testing.
FirmName �j`_� �/C/Z Firm Address�6old.�i9$�►/i6�v ,�i°�G'/1 S!i �jr
Certified Tester(pr;nt)%1'I�c�f�(,� �vi2�� Certified Tester(signaturey�%�.�t//� /�����
Firm Phone#�70? 9�G—3 7 3�/ Cert.Tester No�S 9� Date� /�3 /�b
* 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