2016_0622 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: � �2. � � l ►'��
LOCATION OF SERVICE: / f
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
❑Re ced Pressure Principle �Reduced Pressure Principle-Detector
ouble Check Valve ���7 Double Check-Detector
C1PressureVacuumBreaker f 1Spil1-Resistant Pressure Vacuum Breaker
1,, ' � / i�
Manufacturer VV 6 � I �.5 Model Number `��Q Size
Located At ���� � �`t�'� Serial Number /7;/�� 1 � �
Is the assembly installed i 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��p�id Held at� 'd Opened at Opened at Held at
Initial Test Closed Tight;� Closed Tight psid psid psid
Leaked� I Leaked__1 Did not open �J Did not open [_J Leaked 1
Repairs/
Material s
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight��_J Closed Tight�I psid psid psid
Test gauge used: Make/Model I � � U SN: ���(�V lY� T
Date Tested for Accuracy: � �� '�lp �
Remarks:
The above is certified to be true at the time of tesring.
, i , ,
Firm Name '� � Firm Address C��� W�ll Du��or`�r� � '
Certified Tester(print -'GI- Oh�2 Certified Tester(signature)
Firm Phone# -I��`J1�c�'D�a-� Cert.Tester No. �(�" 15?S Date �� '� �
r
* 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