2016_1111 IRRIGATION V 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: n� v/Z i-/
The backflow prevention assembly detailed below has been tes ed and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
I Reduced Pressure Principle '���Reduced Pressure Principle-Detector
�ouble Check Valve I�l Double Check-Detector
I� �PressurcVacuumBreaker �� ISpill-Resistant Pressure Vacuum Breaker
Manufacturer l�rJ� � �r��v�Model Number �5 v Size � 4�
Located At ��vrv ( �/�/�L� Serial Number���� �07 �
Is the assembly installed in accordance 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 a�� S psid Held a�� ��psid Opened at Opened at Held at
Initial Test Closed Tight 1 Closed Tight � I psid psid psid
Leaked' ! Leaked' I Did not open I Did not open I Leaked'� '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I 1 ClosedTight I���i psid psid psid
�
Test gauge used: Make/Mode1����C�t� �IO•o��� � ✓ SN:v�O�'f � �i�/ 7
Date Tested for Accuracy: ��o`�`'j / �o
Remarks:
The above is certified to be true at the time of testing.
FirmName S�3 ��� FirmAddress�G��f�s�i�� �/9Cl7SL` I�
, ��Certified Tester(pr:nt)y�'E ►C/�i9L`L�v���-` Cerrified Tester(signature� � '
Firm Phone# 77-�IC�lJ�� 7 Cert.Tester No. �5 �g(� Date �� �� �� �'
� -
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy