2016_0601 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: r�- j�'f" �,�J
CONTACT PERSON/PHONE: ` �- - D
LOCATION OF SERVICE: Q�` W
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
�]}educed Pressure Principle ' IReduced Pressure Principle-Detector
i1�DoubleCheckValve 1Double Check-Detector
I 'PressureVacuumBreaker i-Spil1-Resistant Pressure Vacuum Breaker
� �i
Manufacturer�j�,���r', Model Number �Jf� Size
Located At ��Y'�� r 1��r ��Of'►� � Serial Number -�Q���j
Is the assembly installed in accordance with manufacturer recommendations andlor local codes? �
Reduced Pressure Princi ]e Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at vZ+Q ps Held at�ps� Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight � psid psid psid
��5 Leakedf 1 Leaked� I Did not open I I Did not open I ' Leakedl ���
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight'� 1 Closed Tight❑ psid psid psid
Test gauge used: Make/Model �lC� �Q-�d`D `��'✓ SN: D�p� ��SrI
Date Tested for Accuracy: 1� r�]s�.D`�
Remarks: /�/'h�1f�,
The above is certified to be true at the time of testing.
FirmName Q.�� Fi�^C�Ua�'�,-�I"�Firm Address�60�2 �t�i��-1 /��Q4.° �c��l� rjE
� � .j��/
Certified Tester(print)WI)�iUln �� Q�I��S Certified Tester(signature)���U�J � 'vtf�
Firm Phone#����-��1�`" �JD(7 Cert.Tester No����.3���� Date�[}/►-1� jT f1.!)l (a'
* 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