2016_0927 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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 I.D. #0570040
(Customer)
MAILING ADDRESS: �� ,��� S �� �
CONTACT PERSON/PHONE
LOCATION OF SERVICE: �/ � e�CYe4�
The backflow prevention assembly detailed 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 IReduced Pressure Principle-Detector
1�"bouble Check Valve 1Double Check-Detector
I 'PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer [�i �f�. 'V S Model Number �j � �Z�" Size�7
Located At � Serial Number� ����2-�
Is the assembly installed in acco ance with manufacturer recommendations and/or local codes?�c
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 Tightyr Closed Tight � psid psid psid
Leakedl I Leaked�. 1 Did not open �l Did not open I Leakedl
Repairs/ �
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightll ClosedTight 1 psid psid psid
�" /'.�
Test gauge used: Make/Model �/�./�r/!/�� ��' SN: ��I.���s�
Date Tested for Accuracy: � � ��r� -�f 6
Remarks:
The above is certified to be true at the time of testing.
Firm Name �t/������ Firm Address � � �D Q s� � , ���6� 11
Cerrified Tester(prent)�O���p f ��Certified Tester(signature)
Firm Phone#�i�- �- ��/`� �3��Cert.Tester Ng ��/� � Date /����6
* TEST RECORDS MUST BE KEPT FOR AT LEAST TH EE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy