2015_1214 (2) IRRIGATION �� DOMESTIC
FIRELINE
The following form must be completed for �ach 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: � "�'""� �i
ThG backflow prevention assembly detailed below has been tested and maintained as required by
comtnission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
� ❑�uced Pressure Principle ❑Reduced Pressure Principle-Detectar
�+lDbuble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �� �'�� Model Number � � Size � �
--'�-
Located At ��°✓��� ��C(.�".�.✓ Serial Number"�� ���� � � '��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes� �
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Dauble Check Valve Assembly
Relief Valve Air In1et �heck Valve
1 st Check 2nd Check
„ _. . .._ __,.
._ , . ; ,,_ .. . , ,, ;
Held at�psid Held at '��psid Opened at Opened at Held at
Initial Test Closed TightCl+'"" Closed Tight 8''� psid psid psid `
Leaked❑ Leaked❑ id not open ❑ Did notopen ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ ` Closed Tight❑ psid psid psid
Test gauge used:Make/Model �r^��� #`� �''� � SN: ��� ���
Date Tested for Accuracy:
Remarks:
The above is certified to be true at the time of testing.
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� FirmName � +' ° �"'"��J� �¢ �` �-��Firm Address ���� �
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Certified Tester(print) � � � Certified Tester{signature) ,�' �..:�
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Firm Phone#� �� ���'����� Cert.Tester No. � ���� � Date ��"'� "d'" ��
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**L7SE O1VLY MANUFACTURER'S REPLACEMENT PARTS '
White-City.Copy Yellow-Customer Copy Pink-Tester's Copy �