2015_1118 IRRIGATION�_ DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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: _� 1-j Q b-
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
.�oubleCheckValve -7Double Check-Detector
1PressureVacuumBreaker 1 ISpill-Resistant Pressure Vacuum Breaker
i�
Manufacturer �C_f] Model Number g�� Size�_
� 1
Located At Dn I !� Serial Number� � ���
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 atZ•�psid Held atZ. psi Opened at Opened at Held at
Initial Test Closed Tigl� Closed Tigh psid psid psid
�, ((� Leaked���1 Leaked❑ Did not open f I Did not open I : Leaked �I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� Closed Tight f ' psid psid psid
Test gauge used: Make/Model �(D �o��K -��j � SN: �3�� �Q�y�
Date Tested for Accuracy: �—l�"f�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �(L���� �'/�IGl��lDf7 Firm Address � Qkl vi /� � ,
Certified Tester(print '� �o� -� Certified Tester(signature
Firm Phone#���o�� ��,Z��� Cert.Tester N � � � Date � J �
* 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