2015_0917 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: ` S � 3
LOCATION OF SERVICE:
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
�QReduced Pressure Principle ❑Reduced Pressure Principle-Detector
ClDoubleCheckValve �JDouble Check-Detector
'�PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��CA. Model Number �0� � Size f Z-��
Located At � '1/Yl�l.�`�'1,p�f� Serial Number ������j
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��id Held at�psid Opened at� Opened at Held at
Initial Test Closed Tigh� Closed Tight� psid psid psid
Leaked���1 Leakedf I Did not open [� Did not open [7 Leakedl��1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I 1 C]osedTight f 1 psid psid psid
Test gauge used:Make/Model CA S SN: �7�'��
Date Tested for Accuracy: Z
Remarks:
The above is certified to be true at the time of testing.
Firm Name s �Ll Firm Address � a ( r(opv3
T
f
Certified Tester(print) � Z Certified Tester(signature
�
Firm Phone#�)�'�ly I�Q�Cert.Tester No. Dat , ✓r
* 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