2016_0628 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�
LOCATION OF SERVICE• �a -7 �A-�»��—O r� ��
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
❑Reduced Pressure Principle �IReduced Pressure Principle-Detector
�5oubleCheckValve �1Double Check-Detector
�'�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
l�
Manufacturer �,�i � K� n,5 Model Number ��� Size �
Located At ✓ Serial Number � � ����� .
Is the assembly i stalled in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Bre ker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at Held at�psi Opened at Opened at Held at
I itial Te Closed Tight� Closed Tight f�� psid psid psid
� Leakedl� Leakedf '�� Did not open I 1 Did not open . 1 Leaked'�� 1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight f� psid psid psid
Test gauge used:Make/Model � ��T SN: ���Q�P��
Date Tested for Accuracy: ,'� �o—�(o
Remarks:
Tbe above is certified to be true at the time of testing.
Firm Name �� irm Address � �� r/) ��
�-'/
� Certified Tester(print Dr1�- � Certified Tester(signature) _
Firm Phone#��,�' ��j,��J��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