2015-0917 (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: D /v�
CONTACT PERSON/PHONE: � — � ?3
LOCATION OF SERVICE: � "�'
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
` 1Reduced Pressure Principle iReduced Pressure Principle-Detector
�ouble Check Valve CDouble Check-Detector
��IPressureVacuumBreaker C,Spill-Resistant Pressure Vacuum Breaker
Manufacturer Model Number V�7 t�T Size / Z��
Located At ��yU��'Te,�/; Serial Number ��-���
Is the assembly installed in accordance with manufacturer recommendarions andlor 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 Opened at Held at
Initial Test Closed Ti h�l Closed T� ht '��,� psid p psid psid
Leakedl 1 g�� Leaked' 1 g Did not o en 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���-1 Closed Tight I� I psid psid psid
Test gauge used: Make/Model �������5 SN: ����
Date Tested for Accuracy: �i
Remarks:
The above is certified to be true at the time of testing.
FirmName�jM(_��►�`„"Gr`�o ✓�C�S e�'irm Address �(/I�� / ��0��'f�IAa��j� 71od03
Certified Tester(pri nt) ' � ertified Tester(signature)
Firm Phone# ���(D�'�U�� Cert.Tester No. ���l� � Date
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- Ciry Copy Yellow-Customer Copy Pink-Tester's Copy