2016_0427 IRRIGATION V 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:
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
I Reduced Pressure Principle I Reduced Pressure Principle-Detector
�''Double Check Valve i �Double Check-Detector
1PressureVacuumBreaker -ISpill-Resistant Pressure Vacuum Breaker
3
Manufacturer�v���7/rY$ Model Number ��G Size�_
Located At �f�p�v� �/�Q� Serial Number�"-S�� 7.3�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? S
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a�'� psid Held at�ro psid Opened at Opened at Held at �
Initial Test Closed TigY�{� Closed Tight� psid psid psid
Leaked I Leakedl �� Did not open I Did not open ' I Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opcned at Held at
Repair ClosedTight l i ClosedTight 1 psid sid
p psid
Ca•��c o
Test gauge used: Make/Model D- av fj(i SN:a�y /�1i g �_
Date Tested for Accuracy: � � � �
Remarks:
The above is certified to be true at the time of testing.
�
Firm Names'f�i .�� Firm Addres�li����s'�Ui�'s�u .�AL�SG` ��/'
Certified Tester(pr;nt)}��CI��G. �jt,�I �� Certified Tester(signaturey�'���=������i�
Firm Phone#��o�,�}�j 3�3y_Cert.Tester No. �5�Q Date �' 07 /
* 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