2016_0229 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: g �(�
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
�oubleCheckValve 1Double Check-Detector
! IPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��
�C�U Model Number �S� Size�_
Located At ►'J � Serial Number_ 1"1 !-/ �����
Is the assembly installed n 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 at� sid Held at Z• ( si Opened at Opened at Held at
itial Test Closed Tight� Closed Tight '; psid psid psid
�,� � Leakedf I Leakedl�l Didnotopen 1 Didnotopen I 1 Leaked�� ���
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight C 1 ClosedTight�1 psid psid psid
Test gauge used: Make/Model fl D �r U SN: ��lL�� Q��-�-
Date Tested for Accuracy: �'^ l�—I 5
Remarks:
The above is certified to be true at the time of testing.
Firm Name � e /�� �r Firm Address ' G��✓i� �' �
Certified Tester(print) �G�v C al'1P Certified Tester(signature)
Firm Phone#��,������� 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