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)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: ��,S F.< <.�v'G� '� c 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
�Reduced Pressure Principle -'Reduced Pressure Principle-Detector
�ouble Check Valve 'Double Check-Detectar
7PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
l
ManufacturerCvt ��, tr•r' � Model Number 3 .5 C� Size_�_
Located At�/Lc:r�� L/�!i-r� Serial Number�i 5�t� �7'G� �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? '� �
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held� � psid Held a� � psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight}r 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 psid psid
Test gauge used: Make/Mode1LL��ti��v ���-d�� /h�s SN: C�(�C��-� � �� �
Date Tested for Accuracy: �l a5 �i �
Remarks:
The above is certified to be true at the time of tesring.
Firm Name s/� .��� Firm Address��+1��!�ST✓iG�-�✓ �/�C/�5�� ?�
�.J'I«i,�si-�L �3����,� ����.��,� ���%�-L.
Certified Tester(pr.nt) Certified Tester(signatur �<
Firm Phone#����%.� �j 7��—/ Cert.Tester No._�S� �j� Date/v2 L �f (a
* 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