2016_0920 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 LD. #0570040
(Customer)
MAILING ADDRESS: �
CONTACT PERSON/PHONE: �r �
LOCATION OF SERVICE: - -�'- r �
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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 r
�f�Re uced Pressure Principle [7Reduced Pressure Principle-Detectar ;
_ -� ouble Check Valve �Double Check-Detector
❑PressureVacuumBreaker f:iSpill-Resistant Pressure Vacuum Breaker
� f //
Manufacturer 1 �t(;i�l�� Model Number ��� Size�_
Located At���i� {'���l���lf�.�-�.ti('`�� � Serial Number � � � � �� �
..
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 �
, ��
���S�� - Held at�'_��psid Held at�ps�d � pened at_ Opened at Held at
Initial Test Closed Tight�--Y� Closed Tight '- psid �isid psid
Leaked�� Leaked❑ Did not open I 1 Did not open �1 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/Mode1�=�f i[I lZ: `_�L:-�i�:� '�K �:l�r SN: C-1�/�C�'.`r��- �
Date Tested for Accurac °�-� �
y: _, -��-� �k:�
Remarks:
� T'he above is certified to be true at the time of testing.
� --r-- ' , ( , a � _
Firm Name �t"��`�1��. 1 �{�r�����t�{,"�Firm A ddress�(:`� ��/i�jE��.�� �—.T"'i� ��'��s`�� f.-�./���
;
i l � � %�
Certified Tester(pr�nt) � � � �-� ,s�l�'7�;��Certified Tester(signature)/'� �.l ' . �
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' , --� r� ' � t ' 6`.
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Firm Phone#`� �'/�` ,��;: � ��-� Cert.Tester No.�%;��,kr,.�k���Date '�- . - ��
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* 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