2016_1011 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 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: � � -
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle f�Reduced Pressure Principle-Detector
:1DoubleCheckValve f 1Double Check-Detector
��-;PressureVacuumBreaker i�Spill-Resistant Pressure Vacuum Breaker
Manufacturer �u�� Model Number��� 1�1� Size 1 11
Located At ��i��op�11� Serial Number �� �.Z..� �
Is the assembly installed in accordance with manufacturer recommendatioris 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 10.�psid Held at�� psid Opened at 3'� Opened at Held at
initial Test Closed Tight�l Closed Tight �� psid psid psid
Leaked��i Leakedl� Did not open � 1 Did not open I� I Leaked'�. I
Repairs/
Materials
Used
Held at psid Held at psid �
Test After Opened at Opened at Held at "
Repair Closed Tight I� Closed Tight� I psid psid psid
Test gauge used: Make/Model ��� - �,/J,Q,S� ' SN: Q'���e �3� �
Date Tested for Accurac - -
Remarks: ��P_S� C-tpo
The above is certified to be true at the time of testing. ., �
FirmName � Firm A.ddres,s�� � "=- �� ��
: .� � �
4 1
Certified Tester(pri nt)� �� ����,��Certified,Tester(sig�atur �' ��
Firm Phone# �� � '.23'1 "0��/ Cert.Tester No.$���7�(�� Date ��'��' �b►
* 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