2015_0917 (3) 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) _ n
MAILING ADDRESS: Q 75� ,
CONTACT PERSON/PHONE: � — — Q�73
LOCATION OF SERVICE: 3 � �
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 I iReduced Pressure Principle-Detector
1DoubleCheckValve IDouble Check-Detector
�PressureVacuumBreaker �-,�Spill-Resistant Pressure Vacuum Breaker
Manufacturer .W GI.�S Model Number�� �� Size� �
Located At ��1 `D�?�i Serial Number ��n��Q �
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�psid Opened at ��D Opened at Held at
Initial Test Closed Tightf� Closed Tight �'J psid psid psid
Leaked� 1 Leaked�i� I Did not open ❑ Did not open f 1 Leaked f 1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight 1�7 ClosedTight❑ psid psid psid
Test gauge used: Make/Model GO b–p�4U�—(� SN: ,��1���
Date Tested far Accuracy: / f
Remarks:
The above is certified to be true at the time of testing.
Firm Nam�j(`� �� A�P��P Firm Address � Z I� T 7b Ou
� �
Certified Tester(pr�nt) Certified Tester(signature)
Firm Phone# � � � Cert.Tester No. 0 a' Date
* 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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