2016_0314 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) �r )
MAILING ADDRESS: ���� �y'fI 7"�C�' S
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: O�
�
The backflow prevention assembly detailed belo has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�duced Pressure Principle IReduced Pressure Principle-Detector
oubleCheckValve �Double Check-Detectar
'�IPressureVacuumBreaker �� '�Spill-ResistantPressure VacuumBreaker
_� r
Manufacturer � �� Model Number ��'0 Size---��
� p�
Located At )�912�' oT Serial Number � ��0 30 �
Is the assembly installed in ccardance 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 at �. psi Opened at Opened at Held at
Initial Test Closed Tightvl� Closed Tig psid psid psid
Leakedl I Leaked���.1 Did not open ' I Did not open I 1 Leaked� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight-l Closed Tight I��I psid psid psid
Test gauge used: Make/Model___ �>f��� � SN: ��/�, ����
Date Tested for Accuracy: ��/ �--�-s
Remarks:
The above is certified to be true at the time of testing.
Firm Name �'I��rS���� Firm Address D��b�(' /—E�� ����l�' � '"/.�' ��a�
Certified Tester(pr�nt) � 5 �`�ertified Tester(signature)
Firm Phone _r ��� � �o �����Cert.Tester No. � 3 � Date ��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THR E YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- City Copy � Yellow-Customer Copy Pink-Tester's Copy