2016_0829 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:
LOCATION OF SERVICE: �YY�-�'v'�
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
i ced Pressure Principle �Reduced Pressure Principle-Detector
Double Check Valve �� !Double Check-Detector
� PressureVacuumBreaker I: Spill-Resistant Pressure Vacuum Breaker
Manufacturer Model Number ��� Size_�
Located At Serial Number����
Is the assembly installed in accordance with manufacturer recommendations andlor 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
�7 1�
Held at !/�sid �"�Ield at�psid Open at O at d a
Initial Test Closed Tight������� Closed Tight f� psid ps sid
Leaked'�. I Leakedl I Did not open ��' • Di t open '� Le e � � �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight' 1 ClosedTight� psid psid psid
f
Test gauge used: Make/Model�j�ea" �-�t� SN: �;t:�2'S}'�
Date Tested for Accuracy: �'-�--�r-L� �
Remarks:
The above is certified to be true at the time of testing.
� �""�� Firm Address ��
Firm Name '- '�
Certified Tester(print) ��-��-� Certified Tester(signature)
Firm Phone# �''����, Cert.Tester No.' _��'��'� Date IJ �"�/'��
* 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