2016_0114 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:
LOCATION OF SERVICE: �, �� (ZL�� _p�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
educed Pressure Principle f 1Reduced Pressure Principle-Detector
� ouble Check Valve �1 Double Check-Detector
�1PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �1 �,�i 11� Model Number � Size `� ' _
Located At Serial Number �s���{, �
Is the assembly instal ed 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
Held atoC+ 0 psid Held��psid Opened at Opened at Held at
[nitial Test Closed Tighll±� Closed Tight� psid psid psid
Leakedf 1 Leakedl I Did not open _ 1 Did not open [�'� Leaked '��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight_] Closed Tight���1 psid psid psid
Test gauge used: Make/Model �,i['��IA�T SN: �`� � �,"�_
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
c ° �
Firm Name ��'�Ur�1'Q �f��Firm Address ����� � •�� ` o � O� V '�' �-�c'�1
c �/ l ,`�
1 w
Certified Tester(pr;nt�'j� ��,�,(��,�[Q�er�ified Tester(signatu � �
� Y�-��v`��� OV�Q � Date �
Firm Phone# Cert.Tester No.
* 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