2016_1103 IRRIGATION I+ 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 recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRESS: ��'"��''I��
CONTACT PERSON/PHONE: Z � � Y 7 �i/`'L1
LOCATTON OF SERVICE: �Z 2y C'� ...ki•v�/l•c,r,
o.,--��r-
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
�iReduced Pressure Principle �Reduced Pressure Principle-Detector
�le Check Valve �Double Check-Detector
` IPressureVacuumBreaker 1Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��'�'��"' • , Model Number ��Vb�Size `
Located At � Serial Number �3��y �`��
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valv Air[nlet eck Valve
1 st Check 2nd Check
Held at�psid Held at�psid ned a O at Held at
Initial Test Closed Tigh �� Closed Tight �� p � psid
Leaked� l Leaked'�I Did open Did ' en � '� Leaked i
Repairs/
Materials
Used
Held at psid Held at psid
Test After � Opened at Opened at Held at
Repair ClosedTight l ClosedTight I Ps�. psid ,; psid
x
Test gauge used: Make/Model !�r-�Y�/�'LW �+C��� SN: / Z����Z'���
Date Tested for Accuracy: �"�`7'�'� � ���`� � �� �
Remarks: "� -
��ti�
The above is certified to be true at the time of�testing. � , • � �
- ���� , ,
Firm Name �''��� �� ���'"�'��"'Firm Address � �� j � s���� ;�
Certified Tester(print) � �' "`� �����ertified Tester(signature) �
Firm Phone# ���� /�'��/� � Cert.Tester No.�����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