2016_0627 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)
MAILWG ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �y�p GcJ�K!l� SD/Z
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
�oubleCheckValve Double Check-Detector
� ��PressureVacuumBreaker �� Spill-Resistant Pressure Vacuum Breaker
Manufacturer (,ivt� �:t��Model Number 35^d Size 3�
�
Located At �/LOiYJ �i/�l1.D Serial Number� 5 (00 ��"7
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 at�psid Held at y�Q psid Opened at Opened at Held at
Initial Test Closed Tight '� 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 Closed Tight � Closed Tight psid psid psid
Test gauge used: Make/Model �sr-��J�+cp �D•,Zoo l 1�j U SN����� g '7
�
Date Tested for Accuracy: __ � / �
�—.
Remarks:
The above is certified to be true at the time of testing.
Firm Name S/.J ��i� Firm Address�.G�.2�lslS�v�l'�r4i S�i�',��'�= r
�
Certified Tester(pr;nt)/7'I.�� /�„Q,�j�-ertified Tester(signature� Gi�
Firm Phone# �',��-, ��-/ Cert.Tester No. �S 9'�__Date � /
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy