2016_0621 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: rT �'(� Ir` Y`
CONTACT PERSON/PHONE: ►
LOCATION OF SERVICE:
The backflow prevention assembly detailed below� been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
':lIj,�duced Pressure Principle 1 Reduced Pressure Principle-Detector
�ouble Check Valve ❑Double Check-Detectar
f'PressureVacuumBreaker i 1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer ��} -�'� Model Number ��(�('j7 r����Size �iF
Located At t- Y�j`�" �KL111l,� �1�' rY1��erial Number ���(o�D�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � r`7
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held atc�*Q p Held at�ps Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight L� psid psid psid
Leaked�� Leaked'� 1 Did not open I 1 Did not open I J Leaked�.�I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I 1 Closed Tight Ll psid psid psid
Test gauge used: Make/Model �11►Ci 1'15 �_'rj SN: ��� �(���Fj�1
Date Tested for Accuracy: �•-
►
Remarks: C -
`
The above is certified to be true at the time of testing.
FirmNameplS ��)DI-C�K,-�1c�t1�5vV'.FirmAddress� a��(���f P_U_J�j,��(i���7�p.�,�
�C.
Certified Tester(print) ��� � ` � Certified Tester(signature)
Firm Phone# �/��-���`���'�_Cert.Tester No�G1dC5�7� Date t0��.� - ��
* 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