2016_0205 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: �C� a V�'1�IP''�Vl F���l 1�
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
�1Reduced Pressure Principle �Reduced Pressure Principle-Detector
�ouble Check Valve �Double Check-Detector
�-Pressure VacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer � ��
Q�C�� Model Number U ,`�j � Size
Located At �'�.� ���.� Serial Number �
Is the assembly installed 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
�W���� Held atZ-� psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight,� psid psid psid
Leaked���1 Leaked❑ Did not open [�� 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 i ', Closed Tight C psid psid psid
Test gauge used: Make/Model��(�p ���1� �K 5U SN: �`��j(C�b (0 (o �
Date Tested for Accuracy: � —� �–)�
Remarks:
The above is certified to be true at the time of testing.
� ,
FirmName � � I Firm Address ���{ �1 ��Dlx�l �C)VI f1G� �!/�
Certified Tester(print)�li �� OVi�e� Certified Tester(signature)
Firm Phone���7�-�'�G� Cert.Tester No��i' d�� �D � ate '����
* 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