2016_0927 IRRIGATION V DOMESTIC FIRELINE
The following form must be completed far 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 LD. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: TZ'y�-/ l.ui`,.t0 50✓�
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
[-�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�J86ubleCheckValve -7Double Check-Detector
'���PressureVacuumBreaker f Spill-Resistant Pressure Vacuum Breaker
ManufacturerLv��►Ft��✓S Model Number�5� Size �
Located At ��"w 1 �/�g-tiQ Serial Numberf'�J��3 9d7
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assemb] Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a�• 'Z psid Held ata• �psid Opened at Opened at Held at
Initial Test Closed Tight'3� Closed Tight� psid psid psid
Leaked.�1 Leakedl � Did not open � I Did not open � I Leaked�� �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I 1 Closed Tight� I psid psid psid
Test gauge used: Make/Model G`j/rJ 4�/1-�O �iK�60 �f!u SN�.Gt-1 �Lg 7
Date Tested for Accuracy: �/a S li �i
Remarks:
The above is certified to be true at the time of testing.
Firm Name,s� �/1� Firm Address�i��.?.�S�V��`�✓ S/�G/�C ���
Cerrified Tester(print�I iL/f�sj-� �v�t�i �L Certified Tester(signatur�.rG��� �L.�
� /
Firm Phone#�7�� �i�1�3 73 y Cert.Tester No. (�5 gD 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