2015_0923 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:
LOCATION OF SERVICE: � �t�U p� e�
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
�-� educed Pressure Principle C1Reduced Pressure Principle-Detector
ouble Check Valve -�1 Double Check-Detector
[-'PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer ��L(� Model Number ��� Size
/ p
Located At n� Serial Number ����d��� �
Is the assembly installed in ccordance 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 2-•� psid Held at�� psi Opened at Opened at Held at
Inirial Test Closed Tigh �� Closed Tight� psid psid psid
Leaked' I Leaked'.1 Did not open i. ! Did not open ' '' Leakedl '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed.Tight' I ClosedTight I psid psid psid
Test gauge used: Make/Model ��d����� �J(,( sN: 03f�>��� �
Date Tested for Accuracy: ���' �J�
Remarks:
The above is certified to be true at the time of testing.
Firm NameLQ;l�ti—°S/U�-°�rl`�C�l(�Yl Firm Address �U7 �O��DG� J�J'j/7!S K/r!V�
Certified Tester(print) � � �D y�Certified Tester(signature) /f �_- �� � �
Firm Phone# ��/oZ,"7�."b�,�-v Cert.Tester No. D � 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