2016_0505 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: � 8G � �
LOCATION OF SERVICE: U
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 �Reduced Pressure Principle-Detector
,�ubleCheckValve -7Double Check-Detector
]PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
i�
Manufacturer ���� Model Number ��L Size
Located At ��L �� Serial Number' ��� �
Is the assembly installed in accordance with manufacturer recommendations andlor 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�� s� Held at�psi Opened at Opened at Held at
itial Test Closed Tigh �� Closed Tigh i psid psid psid
� Leakedl ; Leakedl I Did not open � �, Did not open �1 Leaked'�� �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight f 1 Closed Tight 1 psid psid psid
Test gauge used: Make/Model ���� �-C�V`�-�T��� SN: V�j�o��P�
Date Tested for Accuracy: ���—�,-�
Remarks:
The above is certified to be true at the time of testing.
�
Firm Name ���'S�L�'E'_� .��lQCl,�I���'irm Address�'��� � ��I�,�(�I� �� I�U1G`� ��t�
Certified Tester(print) r � " �� �6°1 � Certified Tester(signature �
Firm Phone# ���7� 'C��� Cert.Tester No �� 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