2016_1025 IRRIGATION DOMESTIC Y 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:
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
1 duced Pressure Principle 1Reduced Pressure Principle-Detector
� ouble Check Valve r i Double Check-Detector
��PressureVacuumBreaker I 'Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��
�(-�TT� Model Number ���"Z-]'M��'j" Size�_
Located At �I' .�—f""1T Serial Number 0��{.'�-���
Is the assembly installed in accar ance with manufacturer recommendations and/ar 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�.Q p Held ata�psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
Leaked'1 Leakedl ' Did not open . � Did not open '.I Leaked '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight!�J ClosedTightl=' psid psid psid
Test gauge'used: Make/Model �i� Ic j 1��_��� SN: Q�j ��� 9
Date Tested for Accuracy: �-���— ] � �
Remarks: �� ��
The above is certified to be true at the time of testing.
Firm Name fS oD A a� YV T.,r Firm A ddress����s�� I P11�I S V 1� 1���,��
Certified Tester(print � ' Certified Tester(signature) �
Firm Phone# ��,��(���-9�3 Cert. Tester No.��Q�7� Date ��'o��` �(D
* 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