2015_0609 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: 5���o U,S"�'ar 5�
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
-1Reduced Pressure Principle CReduced Pressure Principle-Detectar
�ouble Check Valve i���Double Check-Detector
�PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
YV�I l L��� / � Q � Size ��
Manufacturer 5 Model Number
Located At��p r Serial Number 6�6�Q�_
Is the assembly installed in accordance with manufacturer recommendations and/or local codes.
Reduced Pressure Princi le Assembl Pressure Vacuum Br aker
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 Tigh� Closed Tight� psid psid psid
Leakedl � Leakedf Did not open i l Did not open ! Leaked' I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight' I ClosedTight-.l psid psid psid
Test gauge used: Make/Model � q q SN: � `� Oq�i�
Date Tested for Accuracy: �
Remarks:
The above is certified to be true at the time of testing.
Firm Name , ! . f (b Firm Address �� � b5 �'WK I r'1 ��7��
Certified Tester(print� � Certified Tester(signature) -
Firm Phone#��,��(�?� Cert.Tester Nd�j� (�'U rj�1 � Date � v 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