2016_0727 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 1.D. # 0570040
(Customer)
MAILING ADDRESS: �J'`
CONTACT PERSON/PHONE: �x'�
LOCATION OF SERVICE:
The backflow prevention assembly detaile below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
` 'Reduced Pressure Principle -1Reduced Pressure Principle-Detector
�bleCheckValve IDouble Check-Detector
', 'PressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �(,,�,I/v.7 Model Number � J�� X�..�� Size �
Located At ���1�� Serial Number �� � � � � �
Is the assembly instal ed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air lnle �_ Check Valve
1 st Check 2nd Check
Held at�w�psid Held at d��psid Op e at O ene ld
Initial Test Closed Tight�_ � Closed Tight/�' psi� p � ps
Leaked I Leaked�l Did n open � 'd t open f' ked'
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightf�'� ClosedTight'��1 psid psid psid
Test gauge used: Make/Model /,',��,r��' Y.���''� SN: f'�°a����%�
Date Tested for Accuracy: `'� -- �`� ' i �t
Remarks:
The above is certified to be true at the time of testing.
FirmName'�� '�w � � Firm Address ����f �������"� � ��
Certified Tester(print) ���''� �� Certified Tester(signature)
Firm Phone# � 7 �"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