2016_0506 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. # OSZ0040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: -� y n i re
LOCATION OF SERVICE: / L �� �
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
CReduced Pressure Principle ❑Reduced Pressure Principle-Detector
�ubleCheckValve C1Double Check-Detector
❑Pressure VacuumBreaker �Spi11-Resistant Pressure Vacuum Breaker
,,, I � / ir
Manufacturer VV 1 � I �S Model Number ��(.� Size
Located At ��r��`� � � ��( ��� ����r��"� Serial Number ���� �!��� �
Is the assembly installed ii�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
Leakedl I L�eaked❑ Did not open � Did not open ❑ Leakedl�'
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I� Closed Tight�J psid psid � psid
Test gauge used: Make/Model �� � � � SN: ��I W lY(1`f'
Date Tested for Accuracy: � �� �"�(�
Remarks:
The above is certified to be true at the time of te�tirig.
, � i
Firm Name �-�(,��'�G'��'E:; ���`��� � �� Firm A ddress���'� ��(�����C L�� � �� • '�
�,
Certified Tester(print �f- Oh�' - Certified Tester(signature) � � ��
� Firm Phone# -I��`���r���a� Cert.Tester No. �U�� i5� �Date
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White- Ciry Copy Yellow-Customer Copy Pink-Tester's Copy