2015_1028 IRRIGATION � r 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: ,., - , ; ..�,�_ 2� _ zz -
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
R�ed ed Pressure Principle 7Reduced Pressure Principle-Detector
��oubleCheckValve IDouble Check-Detector
�PressureVa uumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer S Model Number t�o � Size 3
Located At �0��2- Serial Number0��S S
,
Is the assembly installed in accardance with manufacturer recommendations and/or local codes? � .� S
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�psid ,Opened at Opened at Held at
Initial Test Closed TightC^� Closed Tight '� psid psid psid
Leakedf '' Leakedl Did not open I. I Did not open I Leakedl.'
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight''� I Closed Tight��'1 psid psid psid
Test gauge used: Make/Model ��1 i SN:������
Date Tested for Accuracy: �2 ' �s �
Remarks:
The above is certified to be true at the time of testing.
Firm Name P ✓t 1 v�r• h�n. Firm Address ���l�s�-/6/ 1
Certified Tester(print) /"�•��h�L���u ••C Certified Tester(signature) � < -
.
`� �"
Firm Phone#�/� y' � ���� Cert.Tester No.a�i�/�/2/�/' Date '� l�� S
* 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