2016_1025 IRRIGATION DOMESTIC V 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
�1R,�duced Pressure Principle �7Reduced Pressure Principle-Detector
Citf�ouble Check Valve f ���Double Check-Detector
��PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer��}�"'�"� ModelNumberL�('�('�'7M��Size `�_
Located At Frc�r�-t-`Pk �Al, — �' ����_�Serial Number Qc���'t-C �
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 �. � p � � Held at �. ps' � Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight , psid psid psid
Leakedl I Leaked� I Did not open I�1 Did not open C'�: Leakedl I
Repairs/ �
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTighti-1 ClosedTight�-1 psid psid psid
Test gauge used: Make/Model VV�� j� ��-+n� SN:�$ ��� �q�q
Date Tested for Accuracy: � --aZ r ���
Remarks:
The above is certified to be true at the time of testing.
FirmName�j��.��/�'Address�� �`�� �iS\(i�����]��
Certified Tester(pr:nt�� �S�r�►r�ertified Tester(signature)
� Firm Phone#�(�—(��] �Cert.Tester No�Q�d3�]� Date �.���(p
* 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