2015_0821 (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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � 22� G/L,-,�t Si� _
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 �Reduced Pressure Principle-Detector
►�ouble Check Valve -]Double Check-Detector
ilPressureVacuumBreaker i�Spill-Resistant Pressure Vacuum Breaker
Manufacturer i�/�y Model Number v� � �'�f ze Z ��
Located At �p��' � �0�- Serial Number � ( rj ���
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 ( �� sid Held a� ` � psid Opened at Opened at Held at
Initial Test Closed Tight,�l Closed Tight� psid psid psid
Leakedl '� Leaked�l Did not open f Did not open � 1 Leakedl �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight-� Closed Tight I_� psid psid psid
Test gauge used: Make/Model �� ( ��r^'� T� � SN: �� � �"� �� �
Date Tested for Accuracy: �— 2 t? /�
Remarks:�E,,��
The above is certified to be true at the time of testing.
FirmName �l'C��(��'��'` I 1 ''Q Firm Address 6 �� �� � C�-�'�����
i
Certified Tester(pr:nt) � ��nti.h � � � � Certified Tester(signature) �-�
Firm Phone# U�u �� � 2� �� Cert.Tester No. I f Pa"'�'`'��3 y Date �" Z j—� �i
* 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