2016_0916 IRRIGATION V 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: ��y 7 �ri%r ,y G'�Od�
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
I Reduced Pressure Principle IReduced Pressure Principle-Detector
�oubleCheckValve � !Double Check-Detector
[ 'PressureVacuumBreaker ' 'Spill-Resistant Pressure Vacuum Breaker
Manufacturer Lv��, �/�5 Model Number .3.5 � Size ` '7�
� �
Located At f`�O�✓/ �I/�2,� Serial Number�.���'�7�10
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 Opened at Opened at Held at
Initial Test Closed Tight� l� Closed Tight � psid psid psid
Leakedl �� Leaked' I Did not open 1 Did not open . I Leaked I
Repai rs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight' `' Closed Tight I psid psid psid
Test gauge used: Make/Model �d���e0 4v kr� %f�t� SN: ��pl,�-1 /�i 9 7
Date Tested for Accuracy: �'�e?5 �i(�
Remarks:
The above is certified to be true at the time of testing.
Firm Name S� S�/t Firm AddressL�i.�� fi�S'�✓i�4/ .S�C�SG` lj{�
Certified Tester(print�Ylr C<� �ri/L�l�ertified Tester(signatureL���� /'��=�
Firm Phone#� 70a -������ Cert.Tester No. �� �O 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