2015_0825 (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: — 7 —
LOCATION OF SERVICE: �Irl
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
i�I . duced Pressure Principle 11Reduced Pressure Principle-Detector
oubleCheckValve IDouble Check-Detectar
' IPressureVacuumBreaker ]Spill-Resistant Pressure Vacuum Breaker
�—FQ��� �' Q�Size �_�
Manufacturer ���'� Model Number �
Located At ����/ ��, �, Serial Number ��__3�
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 �e p�iel Held at�psj�I Opened at Opened at Held at
Initial Test Closed Tight�a� Closed Tight I�� 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',_7 Closed Tight��I psid psid psid
Test gauge used: Make/Model W► 11���(1� / I ��� SN:Q� 4(�� �9
Date Tested for Accuracy: (�'��
Remarks:
The above is certified to be true at the time of testing. �
FirmName�l.SYlr����./�t�O(�.�Firm Address� Box�9_�(otll e�;sv� ��X Q���
Certified Tester(prsnt) � Certified Tester(signature) � �
Firm Phone# vll�—(D7J�" ��9� Cert.Tester No.�P(����]L�/ Date_$����r]
* 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