2016_0718 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 I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � t,�ic5 4vl��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
: iReduced Pressure Principle 1Reduced Pressure Principle-Detector
1[I'boubleCheckValve 1Double Check-Detector
I Pressure Vacuum Breaker I Spill-Resistant Pressure Vacuum Breaker
3
ManufacturerLvt��/�uS Model Number .�� Size�__
Located At��� Serial Number �"'7� Lj,2d
Is the assembly installed in accardance 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�'S psid Held a�`"� psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight� psid psid psid
Leaked 1 Leakedl�� Did not open I Did not open '� I Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� I Closed Tight I � psid psid psid
Test gauge used: Make/Model���t� Y�D•�,?t?! (I't V SN:��C"�L!�(s 4 7
Date Tested for Accuracy: ���� ���
Remarks:
The above is certified to be true at the time of testing.
FirmName_�� 1�� Firm AddresS��G�,�2�XJ��Qf�w ���Sf� �!s
Certified Tester(print�l'!Q�_ �v��ertified Tester(signatur��;%'������_��Cy��o
Firm Phone#��j�;�, 3,�_Cert Tester No.�S��j Date f-�
� � �
* 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