2016_0115 IRRIGATION DOMESTIC FIRELINE
The following form must be completed far 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)
MaiLiN�aDD�ss: ���� ��1� YYIo►�qa�C�a..�e_
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: , Y�p_
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
f�IDoubleCheckValve �Double Check-Detector
cPressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer vw�.�1 S Model Number��� Size �
Located At 1(r 1►1C;IC,1�� Q,� f�Jl . Serial Number (,(111rf1iL�.Q,h�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? c�
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�'psi Opened at Opened at Held at
Inirial Test Closed Tight!_ Closed Tight - psid psid psid
Leakedl 1 Leaked'.�I Did not open f ' Did not open f 1 Leaked[.
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight C'� ClosedTight f 1 psid psid psid
Test gauge used: Make/Model�i; �((��S �(9 � SN:�(av��� ��
Date Tested for Accuracy: I 2�3 -� �
Remarks:
The above is certified to be true at the time of testing.
1-� ��¢�' ,1 v,.�e.��'t� l c3 �"
Firm Name �, � 1�, Firm Addressl��• g� ���� ��'����1'1, 'k 7 L l 7`j
Certified Tester(prsnt Si� �m Certified Tester(signature
Firm Phone# �/7'�j 3"S�S7 7 Cert.Tester No./3t�oa l,S3 � '� Date S� � k►
* 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