2016_0125 (2) IRRiGATION�� DOMESTIE FIREUNE
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: �� '��4'�� ��yR'"�,' � '
The backflow prevention assembly detailed below has been tested and maintained as required b}?
� commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑l�duced Pressure Principle ❑Reduced Fressure Principle-Detector
,��bouble Check Valve ❑Double Check-Detector
� __._.. . pPressureVacuumBreaker ❑Spi1l-Resistant Pressure Vacuum Breaker
. _ , ; . , , $, _ _ - s ' _
Manufacturer �„ +�} Mode1 Number �� Size—J�� . .
Located At � �C.�`�+.✓'"� �'�di✓ Serial Number � � � �� � �' �I
Is the assernbly installed in accordance with rnanufacturer recornmendations and/or local codes? �F""�.,;�
� Reduc.ed Pressure Princi le Assembl- -, Pr� ure Vacuum$reaker
�
Double Check Valve Assernbly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight Closed Tight psid psid psid
Leaked❑ Leaked❑ id not open ❑ 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❑ psid psid psid
. _._._ , _ _
:" ,--,.. ---. ,_ ..
-� , - .. . . ... _ , .. �
. _ ..;. . .
Test gauge used.Make/Model �h��/� �-'� H SN: ,���`,,r�"� : � � �
Date Tested for Accuracy: �� ��"""� r'�
Remarks:
The above is certified to be true at the time of testing.
FirmName �7�� � ~�'"�` FirmAddress ��� C �- ��+ �. l`l�"����T' �
� � �
���'��'� °"
Certified Tester rint � !�� � ° �� �"� � '�
(p ) � i� Certified Tester(signature)
Firm Phone#_,��1���'� ����Cert.Tester No. � ���.��ate �""" '�'� �"" +�,�+
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLYMANLTFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy
, ;
{
... , � , � u. _..�.. ,.�__._,._,_ .._��. .�._��::��.�:..�.__. .