2016_0118 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:
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
❑Reduced Pressure Principle f�:Reduced Pressure Principle-Detector
.I�bouble Check Valve �'�Double Check-Detector
f�IPressureVacuumBreaker ����Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �G��� Model Number ��� Size �!1
Located At � �' Serial Number � � /3�3
Is the assembly installe 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 V alve
1 st Check 2nd Check
!`�� Held at�psid Held at2�psid Opened at Opened at Held at
I itial est Closed Tigh.t� Closed Tight� psid psid psid
,�.� Leakedr 1 Leaked❑ Did not open ',7 Did not open I I Leaked� '
Repairs/
Materials
Used
Held at psid Held at psid �
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model � � � C SN: ���� _.��
Date Tested for Accuracy: �'����'/S
Remarks:
The above is certified to be true at the time of testing.
FirmName� /�����77Do7 Firm Address�'�D�"�/�`�Gf� ` V/h1�5 �12 �
Certified Tester(prin �1� �' Certified Tester(signature)
Firm Phone#�7�- ,2,����6d�� Cert.Tester No. �� � 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