2016_1207 IRRIGATION 1�� 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: , �! Ev� S! l-1� v'�=�
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
S,DoubleCheckValve -��Double Check-Detector
I IPressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
�Manufacturer L!/, � (� i vv S Model Number ,3 �(� Size�__
Located At /-i2<rrv� �/��✓t /J Serial Number /7 S 5�� // (�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �/C" �;
�_
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air[nlet Check Valve
1 st Check 2nd Check
Held atD7• � psid Held at Ul+ �psid Opened at Opened at Held at
Initial Test Closed Tight�,r--� Closed Tight �!/ 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 Hcld at
Repair ClosedTight '� ClosedTight �� psid sid
p' psid
Test gauge used: Make/Model Gv�-r��Qqc c� �-�G� •�r� Ti�j „ SN: �? .(�r�'�-��/C�-�j=
Date Tested for Accuracy: �/,��j �i �
Remarks:
The above is certified to be true at the time of testing.
Firm Name � /� /?�� Firm Address �.'��vZ �� S/�/i C�r/ ,J�C���^ ���"
�a��� �r�c:c i_3v�1 Sc � ,
Certified Tester(print) Certified Tester(signature�`���r� �G..'��. /�/�� ��
, /
� �p
Firm Phone#f 7,J� %��(�- j 7 3�/ Cert.Tester No. C ; ��) Date f� � /
* 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