2015_1217 ,.. . ._ , ._ . , ... _,,.. �,,
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: � �
LOCA�'TION OF SERVICE: #�i � �
The backflaw prevention assembly detailed below has been tested and maintained as required by '
'' ct�xnrnissionregulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY �
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
❑DoubleCheckValve ❑Double Check-Detector
°❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum'Breaker 1
/'Manufacturer_�� �{� Model Number � � Size � '
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Located At �"�t��'"' �� ��j .a�; I
��`�''� ���:N� Serial Number � , . �<�:
� Is the assembly installed in accordance with manufacturerrecommendations and/or local codes? ` ��� "
' Reduced Pressure.Princi le Assembl Pressure Vacuum Breaker
Double Check Valve�ssembly
Relief Valve Air Inlet Check Valve
I st Check 2nd Check
, ...
- - _.._ .._ , __ .. ._._ __ _. _ _ _
Held at�psid Held at�psid Opened at Opened at Held at
Initial Test CYosed Tight❑ Closed Tight ❑ psid psid psid
'� Leaked� Leaked❑ id not open ❑ Did not open ❑ ' Leaked❑
Repairs/ ,� ,
Materials `
Used �^�,,n.�._
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 �V-'�J�''j ���,� SN: ����_
Date Tested for Accuracy: � ��"`���- {'�
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Remarks: �;,:4,� �,, '� �
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The above is t3erfifie� + '�time of te�ng. .
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�✓' f � �� �a "`�#.- , ("� �
Firm Name(,,,�'������1� -��� Firm Address�Q� +��y ��"�„a/ Y�'/�
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Certified Tester(print) �'�� (�����.��'+����er�if ed Tester(szgnature)� "� � ���� .'��°��� ��
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Firm Phone# ��,�„��, "]� �� Cert.Tester No.����'1,�,�,,,,,. Date �� ��"1� �
� *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS �
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
� , White-City Copy `' Yellow-G�xstor�er CopY Pink-Tester's Copy
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