2015_0824 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: vL )'�� n r� -��� ����
LOCATION OF SERVICE: � I C��f`Yl�1�f�l
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
f�Reduced Pressure Principle -1Reduced Pressure Principle-Detector
�ouble Check Valve I 1 Double Check-Detectar
7PressureVacuumBreaker CSpill-Resistant Pressure Vacuum Breaker
nf I�
Manufacturer �'U L� Model Number � �� Size�
Located At D�l� �" Serial Number � �� (�p �� 7✓
Is the assembly installed in acc dance 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 �"� s� � Opened at Opened at Held at
Initial Test Closed Tigh !� � Closed Tight� psid psid psid
Leakedf; Leaked� I Did not open I 1 Did not open I I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight_�1 Closed Tight I I psid psid psid
Test gauge used:Make/Model/��1�D�j��/�v�D������L-� SN: d, ��0 ��7'
�
Date Tested for Accuracy: 5 /� 'f �
Remarks:
The above is certified to be true at the time of tesring.
, - i �
FirmName �� `� C irm Address � �
�
Certified Tester(print) � v � /"���{'l� � Certified Tester(signature)
1 �/a- /
FirmPhone#�����g�/��J Cert.TesterNo. �� �� 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