2015_1207 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: � (� � p ,/
LOCAT[ON OF SERVICE: o f
The backflow prevention assembly detailed below has been tested a maintained as re uired by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle �1Reduced Pressure Principle-Detector
�oubleCheckValve :�Double Check-Detector
f Pressure Vacuum Breaker '� Spill-Resistant Pressure Vacuum Breaker
Manufacturer �CC s Model Number ` Q d Size
�
Located At � � - (�r �S�rial Number C./� �;�5.
Is the assembly installed in accordance with man facturer recommendations and/ar local codes? Q
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 f� psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�� I Closed Tight � I psid psid psid
Leakedl I Leakedl� I Did not open '�. Did not open � 1 Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight.� Closed Tight I ' psid psid psid
Test gauge used: Make/Model f �I' SN: �!,��, �9� �
Date Tested for cur y: L � '` �
Remarks: -- 6�
� �J ;l U X7
The above is certified to be true at the time of testing.
Firm Name ��1 � �� � Firm Address 7� 1.�. �
�
Certified Tester(print) � �r Certified Tester(signature)
Firm Phone# ��� �/ `���� Cert.Tester No.�P��d��� � Date ' ,�3
* 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