2016_1014 IRRIGATION DOMESTIC � FIRELINE
The following form must be completed far 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: �� �� l_(�QQ� C (�-P SS ( � � ( ��� � �� ��
CONTACT PERSON/PHONE: 2Z �- 3
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
educed Pressure Principle �Reduced Pressure Principle-Detector
� I ouble Check Valve [_Double Check-Detector
'��1Pressure VacuumBreaker I I Spill-Resistant Pressure Vacuum Breaker
Manufacturer Mode] Number ��� � �... Size I � r
Located At Serial Number ���j,�'
Is the assembly installe in accorda ce with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker 4,
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve �
1 st Check 2nd Check �
Held at�psid Held at �•� psid Opened at �-!� Opened at Held at
Initial Test Closed Tightf� Closed Tight .D�I psid psid� psid
Leaked� 1 Leakedl�'�� Did not open I�l 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_J Closed Tight I�I psid psid psid
r /� r -
Test gauge used: Make/Model r Y\ � " �Q� SN: �V���o � � �
Date Tested for A�ccurac�y: �'"' �� � �
Remarks:
The above is certified to be true at the time of testing.
Firm Name Firm Address � � �
c
Certified Tester(print) w � 1 ertified Tester(signature
Firm Phone#���1/C,_ �� `i'����� �Cert. Tester No.�J`���� � �� Date �� '/�'" ��
* 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