2016_0318 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) /� ��,t
MAILING ADDRESS: �� ��p� � � �lolo �E ��.f/Y V��vL(_
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
�
duced Pressure Principle '�����Reduced Pressure Principle-Detector
ouble Check Valve '� Double Check-Detector
' PressurtVacuumBreaker ' Spill-Resistant Pressure Vacuum Breaker
Manufacturer 1I�C�5 Model Number ,�� Size r�
Located At 1l S• S Serial Number U��
Is the assembly installed in accordance with manufactu er recommendations and/ar local codes? y�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 at'�'�psid Held at �'(7 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight I'I� psid psid psid
Leaked� I Leaked'� I Did not open 1 Did not open I I Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight��� I Closed Tight I � psid psid psid
Test gauge used: Make/Mode1����4� �q��G' SN: ����a�/7!�
Date Tested for Accuracy: ,�o���
Remarks:
The above is certified to be true at the time of testing. �(���7�
Z��`� 7k
Firm Name / a Firm Address �
Certified Tester(pri t ertified Tester(signatur
Firm Phone# Cert Tester No. Date ����
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Custamer Copy Pink-Tester's Copy