2016_0215 IRRIGATION V 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:
LOCATION OF SERVICE: ��(� �-�c,l��.-r�G.OI�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
' Reduced Pressure Principle ��Reduced Pressure Principle-Detector
I '�6uble Check Valve I 1 Double Check-Detector
CPressureVacuumBreaker ClSpill-Resistant Pressure Vacuum Breaker
Manufacturer �it ��7��s Model Number �S U Size�
Located At /� ��`''� �//�-Z� Serial Number /7` �—� L'! 7 7 3
Is the assembly installed in 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
Neld�' � psid Held�`• �psid Opened at Opened at Held at
Initial Test Closed Tight� �� Closed Tight� psid psid psid
Leakedl ''� Leakedl I Did not open I� 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 Closed Tight C' Closed Tight I psid psid psid
Test gauge used: Make/ModelCG�f-a� C Y -aati/hv SN:�(od�'1 /fig 7
Date Tested for Accuracy: � / �� S
Remarks:
The above is certified to be true at the time of testing.
Firm Name s�� ��� Firm Address�G�� €�sTv/�� S��`fSl� �,fi
�
Certified Tester(pr�nt)���tL����G�j liCertified Tester(signatura�';!��<t��
Firm Phone#�7�� d (,'� ���G� Cert.Tester No. �S �� Datec�
,�
* 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