2015_0916 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: `To
LOCATION OF SERVICE: �� $ ,,. � �
The backflow prevention assembly detailed below has been tested and maintained as required by
coinmission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
' IR ced Pressure Principle ❑Reduced Pressure Principle-Detectar
� ��� oubleCheckValve -1Double Check-Detector
f iPressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker
Manufacturer �� Model Number 85O Size 3 �/•�
Located At �i�..� �,,,� Serial Number f�026S7/
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 lnlet Check Valve
1 st Check 2nd Check
Held at ��.3_ps' �Held at �•( psi pened at Opened at Held at
Inirial Test Closed Tight � Closed Tight I psid psid psid
Leakedf 1 Leakedl ' Did not open I ���� Did not open ! I Leaked�� ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I 1 Closed Tight I� psid psid psid
Test gauge used: Make/Model �,pe��n SN: /z13Z565
Date Tested for Accuracy: `/-/S-/6
Remarks:
The above is certified to be true at the time of testing.
Firm Name �iV�e,,51� Firm Address S'S r
Certified Tester(pr:nt) Certified Tester(signature)
Firm Phone#�2-(�Y7-'� j�_Cert.Tester No. QiP(,�6�(Z Date_ �- i6�f 5
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONi,Y MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy