2016_0118 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 LD. # 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 �IReduced Pressure Principle-Detector
�ouble Check Valve -�Double Check-Detector
1PressureVacuumBreaker i Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �� Model Number ���
_�„� Size
Located At� � �' Serial Number �,� �J��� �
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 Valve
1 st Check 2nd Check
���� �� Held at2• psid Held at�ps' Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
�� Leakedf 1 Leakedf�I Did not open �. I Did not open �] Leakedi I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I I Closed Tight❑ psid psid psid
Test gauge used: Make/Model `e !o �Da�l< �u SN:_ ��JQ�ZQ��
Date Tested for Accuracy: ,'���'/5
Remarks:
The above is certified to be true at the time of testing.
�/ � � /� � �
FirmName�f'�Q.f/C�� 4/4�j�yk'irm Address.�Dy" L•iJ/'lvc� ���ii�S ,� ,
�
Certified Tester(print �— D��'1 Certified Tester(signature)
Firm Phone�����--��a� 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