2015_1112 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 recardkeeping 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: �-I6�L v,.;. ,,�_r__
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
' iRe ed Pressure Principle C Reduced Pressure Principle-Detector
� ' ouble Check Valve �Double Check-Detector
'�PressureVacuumBreaker �iSpill-Resistant Pressure Vacuum Breaker
Manufacturer �jev Model Number 8�p Size._���/•�
!—
Located At �,/b,,�,.� �� Serial Number }�/�
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
��_����5 Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at o7, �p � Held at �•� psi pened at Opened at Held at
Inirial Test Closed Tight Closed Tight '_ psid psid psid
Leaked� I Leakedl�� Did not open ��1 Did not open f I Leakedl ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl I ClosedTight�l psid psid psid
Test gauge used: Make/Model_ C��/�p SN: /02./3�2,5'65
Date Tested for Accuracy: �l—I S—/b
Remarks:
The above is certified to be true at the time of testing.
Firm Name i Firm Address ��- oZO�'1Z5S �1C 7��
Certified Tester(print) � Certified Tester(signature)
Firm Phone#�����'j�_Cert.Tester No.��i�'�Date ��—/�—/j
* 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