2016_1007 1
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 I.D. #0570040
(Customer)
MAILING ADDRESS: � � � �
CONTACT PERSON/PHONE: ' 0
LOCATION OF SERVICE: ' '
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
�educed Pressure Principle ❑Reduced Pressure Principle-Detector
❑DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �/\� ? Model Numbe�(���P���,� f a�Size�
Located At j(���b�f o��at�,.q�Ce �e Serial Number ,� y/�S��
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� Closed Tight �' psid psid psid
Leakedl� Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used: Make/Model ��S�K 9�� SN: _5���g
Date Tested for Accuracy: � .5/ (�� /�
Remarks:
The above is certified to be true at the time of testing.
FirmName i Firm Address 7/Q / L�Ct 1'r S�CL'��� l,�l ,G��as��! 7sv���
Certified Tester(print)�eS US �P�ih�> Certified Tester(signature)
Firm Phone�a_�y� �g' —�����Cert.Tester No. �Q I 6�7 S� 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