2015_1118 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: � �(,(�
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 �Reduced Pressure Principle-Detector
-�PSouble Check Valve ❑Double Check-Detector
GPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer�,�'�1 j� Model Number ��� Size � r/
Located At 6 � Serial Number tT ���y�
Is the assembly installe in accordance 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
����� d Held at Z- psid Held a��l sid Opened at Opened at Held at
Initial Test Closed Tig Closed Tight '_ psid psid psid
�, Leakedf � Leakedf i Did not open ' I Did not open f" Leaked. i
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�� Closed Tight❑ psid psid psid
Test gauge used: Make/Model�[f��b �o����j�[ SN: �3��(p��
Date Tested for Accuracy: � ��—��
Remarks:
The above is certified to be true at the time of testing.
Firm Name��.(�jlC�-����.�/' '���'irm Address /
Certified Tester(print) �v 0 Certified Tester(signature) �
Firm Phone����� Cert.Tester No. � � ate �//�l�
* 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