2016_0426 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: 0� �t. � �2��
LOCATION OF SERVICE: � � �.�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle � jZeduced Pressure Principle-Detector
' Double Check Valve �-�ouble Check-Detector
I Pressurc Vacuum Breaker � 'Spill-Resistant Pressure Vacuum Breaker
� � ,/
Manufacturer 16� "v��� Model Number 7� Size
Located At ���� ��( �� 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
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at� Z psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�l Closed Tight ps�d psid psid
� � Leaked� I Leakedf; � Did not open I Did not open �� ' Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl�! ClosedTight�_�I ps�d psid psid
Test gauge used: Make/Model �/�/�'�Ctr/5 /��7� SN: U.�� ��Z���
Date Tested for Accuracy: �` �g7^ -~,
Remarks:
The above is certified to be true at the ime of testing. �
Firm Name �'��4e'� I `�P �0���'lrm Address `�S ?5 �5�� i�� 1/�� �S
Certified Tester(pri�t) l�l� �Q � Certified Tester(signature)
�/�'
Firm Phone#�� 7 ����V �� � Cert.Tester No. �V � �� Date � ���'
* 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