2015_1215 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: � ,�
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
i-iReduced Pressure Principle �Reduced Pressure Principle-Detectar
�:��ouble Check Valve ❑Double Check-Detector
CPressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer ��v Model Number o✓v Size l ��
Located At ,�, �P��/ Serial Number /7����-G�
�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?,y�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�'=� Closed Tight � psid psid psid
Leaked��l LeakedCl Did not open '� I Did not open f�l Leaked��l
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight_7 Closed Tight I� psid psid psid
Test gauge used: Make/Model ��v �U��1..�l� SN: O����/GG�
Date Tested for Accuracy: 3���/f
Remarks:
The above is certified to be true at the time of testing.
Firm Name Gc, l��Pl�� � - Firm Address �U �i✓ ��� � �
Certified Tester(print) � Certified Tester(signature) ��
Firm Phone# �7"1.��"1h—��i/ Cert.Tester No.�A-U��l�`f Date ��-��f�
* 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