2015_0806 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: ` �/ �/y� .
�—.--� -—
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 CReduced Pressure Principle-Detector
�DoubleCheckValve ��lDouble Check-Detector
�1PressureVacuumBreaker i 'Spill-Resistant Pressure Vacuum Breaker
1�
Manufacturer � J�as Model Number_ ���L'f Size 3��-
Located At 1�1�+�T i�f�-/�6� �1y��{p'yi�i�,9��-�Serial Number ��� ����
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�psid Held at Z�d' psid Opened at Opened at Held at
Initial Test Closed Tight'1�i'j Closed Tight � psid psid psid
Leaked�] Leakedf��� � Did not open i Did not open i ' Leaked I I
Repairs/ '
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight; 1 ClosedTight[._�i psid psid psid
Test gauge used: Make/Model �1�/DI.��r' rj — ���5 SN: (�� (�?�(��
Date Tested for Accuracy: ZZ rJ
Remarks:
The above is certified to be true at the time of testing.
Firm Name �DO1� ���1FSi����� Firm Address ���[.�u0�O���g (�(��L�5 �SZ��
Certified Tester(pr:nt)�,�}�L �• (,f'�N,�/t1.Certified Tester(signature)
Firm Phone#��il�� ���� Cert.Tester No. (J��'���i�V� 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