2014_0723 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)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �,'�,�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
i:i duced Pressure Principle -7Reduced Pressure Principle-Detector
oubleCheckValve �Double Check-Detector
C PressureVacuumBreaker 1Spill-ResistantPressure VacuumBreaker
Manufacturer �Z�J� Model Number ��
�� Size�_
Located At � Serial Number �Q {��� ��
Is the assembly installe 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�a� psid Held at c�' psid Opened at Opened at Held at
Inirial Test Closed Tight� Closed Tight I�' psid psid psid
Leaked�i I Leaked 1 Did not open .1 Did not open � I Leaked���I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I � ClosedTight CI psid psid psid
,` � �� ���� q
Test gauge used: Make/Model � i(7�)����� SN: (������ I � �
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
` i.s� ,�L���� ��'�..� '� �.51�
FirmName irm Address �' �
, � ��'�:�� .
Certified Tester(pr:nt I S �� Certified Tester(signature)
Firm Phone# ���� ������ Cert.Tester No.��� 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