2016_0922 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: c.
LOCATION OF SERVICE:
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 '�7Reduced Pressure Principle-Detector
� � oubleCheckValve I�1Double Check-Detector
�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
� /i
Manufacturer � ��(��� Model Number �j�� Size�_
Located At � ��� Serial Number � � �7�
Is the assembly installed in 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�.�psid Held at�psid pened at Opened at Held at
Initial Test Closed Tight� Closed Tight �� psid psid psid
Leaked'���I Leaked�7 Did not open i 1 Did not open I '� LeakedCl
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight'� Closed Tight C'.� psid psid psid
Test gauge used: Make/Mode � �� �- SN: �����D lCJ �
Date Tested for Accuracy: �(G� �(r� _
Remarks:
The above is certified to be true at the time of testing.
F irm N ame���C1��1�(�C�l� � Firm A ddress��� �l����C{� —�/Y'�(l1�0� �
� c
� �. ,,
Certified Tester(pr�nt) d ��.C�� Certified Tester(signature)
�
Firm Phone#���'��o�`���� Cert.Tester No. � Date�, ��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ` V
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy