2015_0914 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) �
MA[LING ADDRESS: ��O N 0�,��0� 0`� �•
CONTACT PERSON/PHON�: K,0.�� � � -e �j � - 0 ' g��
LOCATION OF SERVICE: ')� N r� L�Y�� ��nP• R�
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 _:IReduced Pressure Principle-Detector
:�DoubleCheckValve ��Double Check-Detector
-1PressureVacuumBreaker I �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �4���� Model Number � �-I 1'�� Size ��__
Located At W ���i� ���`-+�Y C 1�S�� Serial Number� � l� ��
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 6' y psid Held at"' � psid Opened at� Opened at Held at
Initial Test Closed Tigh�' Closed Tight�Cl psid psid psid
'�� Leaked�', Leaked� I Did not open I Did not open I Leaked�1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ ClosedTight� psid psid psid
Test gauge used: Make/Model �'�!\ ����S fiG 5 SN: V VJ�Q�6�
Date Tested for Accuracy: v r � J
Remarks:
The above is certified to be true at the time of testing.
Firm Name / 11 ��S� Firm Address�2 Q 6S r`� ��,, �-e.t�-�i' "�x' 7 6�,`��'1
Certified Tester(pr:nt)�'L�p�1'���j (.`�`���C�fied Tester(signature) ����1' -��
D���"���" � ISPQ���ZO� Date IJILIJ1S
Firm Phone# "ly�"� �O Cert. Tester No.
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Ye11ow-Customer Copy Pink-Tester's Copy
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