2015_0825 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed far 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: ' ' ��5�
CONTACT PERSON/PHONE: —
LOCATION OF SERVICE: �
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
'� duced Pressure Principle 7Reduced Pressure Principle-Detectar
i�oubleCheckValve �;Double Check-Detectar �
C�PressureVacuumBreaker � Spill-Resistant Pressure Vacuum Breaker
Manufacturer W� ��� �S Model Number ��Q Size ��
Located At I ' ►�'�..f/� ���, COI�I��✓ Serial Number_� �0� ��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �{��j
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�p Held at�psi Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight psid psid psid
Leakedl I Leaked I Did not open I I Did not open I � Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight i ClosedTight I I psid psid psid
Test gauge used: Make/Model �I � �1 h� / � �Ti� SN: Q g �����
Date Tested for Accuracy: � "3(�— �5
Remarks:
The above is certified to be true at the time of testing.
Firm Name�lSi'16D.1'S'fjCKt1�5LL���Firm Address I�n 0 L'XSX�'���� �C.U���(i � l��x 7�Cl�2q
Certified Tester(print)�"�'�/E'j'��js�'�`j'ertified Tester(signature) �
Firm Phone# �1��—(fl��—�q�� Cert.Tester No�P(')���� 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