2015_1104 �R - iS -�
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�SSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADD�SS: �oS �' H-e��fi Z. � •
CONTACT PERSON/PHONE•
LOCATION OF SERVICE:
The backflow prevention asser�ibly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
CR ced Pressure Principle ! Reduced Pressure Principle-Detector
C oubleCheckValve �Double Check-Detector
-1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
i�
Manufacturer ��-� � � Model Number ��/ ` Size ��
Located At ��1 V Serial NumberN� ���1 �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �
Reduced Pressure Princi le Assembl Pressure Vacuum B eaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at��� ps Held at�' p�si/d Opened at Opened at Held at
Initial T st Closed Tightl� Closed Tight r.Y psid psid psid
� �,� Leakedl 1 Leakedl J Did not open �I Did not open � 1 Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I 1 ClosedTight f' psid ' psid psid
Test gauge used: Make/Model V" � �1\� �'� � " � SN: ��I����
Date Tested for Accuracy: � ' �� '�5
Remarks:
The above is certified to be true at the time of testing.
Firm Name I � Firm Address ��"6` 1�1 �' ��"�
� ` �/
Certified Tester(pr�nt) '�� J �0 Certified Tester(signature)
/
Firm Phone# U��'��� � ���'" Cert.Tester No.���� Date ��' 1 � � �
* 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