2016_0826 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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: �jL !� �� �-�_�;.;,�ii�
LOCATION OF SERVICE: �// (�� ��,�P
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
� 1Reduced Pressure Principle ��Reduced Pressure Principle-Detector
�ouble Check Valve �=Double Check-Detector
'� ressure Vacuum Breaker �'Spill-Resistant Pressure Vacuum Breaker
Manufacturer �V �l�l,,.� Model Number � Size
� ,.
Located At ��y��� /lr� Serial Number � , ��j�
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{�i� Closed Tight I `d psid psid
Leakedf I Leaked I I Did not open �1 Did not open ! Leaked i ����
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I��1 Closed Tight['� psid psid psid
Test gauge used: Make/Model ��Ov�i !/ SN: � /UUG��
Date Tested for Accuracy: � —��
Remarks:
The above is certified to be true at the rime of tesring.
FirmName f Firm Address lJ � �,-,
Certified Tester(print) ���j��Certified Tester(signature)
Firm Phone#�17�-�7�.�-��U� Cert.Tester Na � Ul� Date �e�-,�
* 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