2016_1025 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 recardkeeping 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: � _ w
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
�J�duced Pressure Principle �Reduced Pressure Principle-Detector
fvDoubleCheckValve C1Double Check-Detector
�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
` �,r ��
Manufacturer W A-�—�� Model Number�,�0O� �[��Size�_
Located At �1rpY1�'�k(.ih/.^ ��' M�'�-� r/ 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
Held at o1��p Held at���psi Opened at Opened at Held at
Initia]Test Closed Tightf� Closed Tight '� psid psid psid
Leaked.7 LeakedCl Did not open I �: Did not open �. I Leakedl
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight f i Closed Tight � I psid psid psid
Test gauge used: Make/Model �i l�i v�S ��l SN: �g �(�([�5�
Date Tested for Accuracy: �"��� ��p
Remarks:
The above is certified to be true at the time of testing.
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Firm Name `C Firm Address � � I ,)(���
Certified Tester(pr:nt) �Y � Certified Tester(signature) �
Firm Phone# ��—�o7�s19$�_Cert.Tester No:BPc�_3�� Date ���o��—j�Q
* 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