2016_0524 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 far 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: �,y��,(,�'j�/
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
r
duced Pressure Principle -1Reduced Pressure Principle-Detector
oubleCheckValve C Double Check-Detector
��-1 Pressure Vacuum Breaker ��:l Spill-Resistant Pressure Vacuum Breaker
Manufacturer �-tJ��.�'1t/✓� Model Number 35�� Size ��
Located At��(/� �/�--/!� Serial Number�sS �� 79
�
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 a� �psid Held a�� � psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked'��1 Leaked�l Did not open 1 Did not open I�1 Leaked' I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight� 1 ClosedTight�� psid psid psid
Test gauge used: Make/Model��t O �lO a!Y/ �f?e� SNO��-C l Gi Q[ ,Z_
Date Tested for Accuracy: 9 � �
Remarks:
The above is certified to be true at the time of testing.
Firm Name s ..��/` Firm Addres�(��SI��S/I/'r�=�ti ��ff�s'!� ,�
Certified Tester(prs nt�i�� .f�j�yL��Certified Tester(signature ���
Firm Phone#�7�— Y��'— 73�Cert.Tester No� �� Date-5 /•z�1 !/
* 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