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) ����� � �
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
iReduced Pressure Principle �IR�e uced Pressure Principle-Detector
� I Double Check Valve i�ouble Check-Detector
��'��PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer��"S Model Number �P ��
2 �� Size
Located At SV� �.l7�fY�,Q.1(� l 1�1 1�(�,t,l.Q�'��� Set'ial Number�,(.n�A��
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 at��'1 psid Opened at Opened at Held at
Initial Test Closed Tight.�� Closed Tight '�� � psid psid psid
Leakedl '� Leaked I Did not open I ! Did not open I Leaked'��� '��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�.� Closed Tight_�I psid psid psid
Test gauge used: Make/Mode��,�t T,C�99�� SN:�1�Z �17�
o.
Date Tested far Accuracy: ��`�
Remarks:
The above is certified to be true at the time of testing.
FirmName%I��C ��i'12�o�f�C Firm Address -Q 9�� �x
� ✓� Co/�l�'
Certified Tester(pr� t) � , ertified Tester(signatu e)
Firm Phone# D� ���8��'7;� 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