2016_0513 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: ��- � ✓�—
LOCATION OF SERVICE: G�
The backflow prevention assembly detailed below as 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
.�oubleCheckValve i�IDouble Check-Detector
11PressureVacuumBreaker f�Spill-Resistant Pressure Vacuum Breaker
� `�.., ��
Manufacturer ��►'�J�-� Model Number ��� Size�_
Located At �u �/�.l'��� Serial Number ,�IG����/
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�psid Held atZ�� psid Opened at Opened at Held at
Inirial Test Closed TightlC� Closed Tight _ psid psid psid
Leakedl ; Leakedf 1 Did not open I �� Did not open I I Leakedl�l
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 /4 r(�D(�D �b �D 0� K 5(,L SN: �3�� �p(�1`f-�_
Date Tested for Accuracy: J r—��-/ �
Remarks:
The above is certified to be true at the time�of testing.
Firm Name�/ril��l�e __��'lLl�1�Firm Address 3�7 GV/��Dl,lJ ...�DV'��rS [/�, �
Certified Tester(pr�nt)j� a�+� Certified Tester(signat e)
Firm Phone#�]�- ���-�dZ� Cert.Tester Nol�p ��; � 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