2015_0917 (2) 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: O �� ,
CONTACT PERSON/PHONE: 3
LOCATION OF SERVICE: '—
The backflow prevention assem ly 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
C Double Check Valve �Double Check-Detector
!�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer�(i(; Model Number D� '� Size 3 `�
Located At �N ���� Serial Number �����.�T_
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�(.3 psid Opened at��� Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leaked�1 Leaked�-1 Did not open ��l Did not open I I Leakedl '��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight -7 Closed Tight�:1 psid psid psid
Test gauge used: Make/Model��������SN: 3�a��7
Date Tested for Accuracy: �/�/ ����
Remarks:
The above is certified to be true at the time of testing.
FirmName �� '" 7���,
T/��/�(�'��/a .rd�l.C,�Firm Address 7� � 7 l
�' .
Certified Tester(print) [l,�t ified Tester(signature)
Firm Phone# ,���''��p —�vD Cert.TesterNo.cLYf'�0�(���1 ate / /
* 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
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