2016_1107 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 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: q
LOCATION OF SERVICE: I,b
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
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer ��„��� Model Number�s�b[�$ Size l�
Located At Serial Number (h�oo l�
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 Valve Air lnlet Check Valve
1 st Check 2nd Check
Held at�-� psid Held at �„'� psi Opened at Opened at Held at
Initial Test Closed TightC� Closed Tight psid psid psid
Leaked❑ Leaked❑ id not open ❑ Did not open C7 Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight L7 psid psid psid
Test gauge used:Make/Model I��r,��j �p-2.�-+�cJ`��, SN:�t y 2Y�c'}
Date Tested for Accuracy: Sf�p
Remarks:
The above is certified to be true at the time of testing.
FirtnNamel��e�..or,��e,Lk ��i ��+e,�-�c�, Firm Addresst��$n,c� � �( �1,�
Certified Tester(print)�1����- Certified Tester(signature)
Firm Phone#21�.�LHy,7v19'i Cert.TesterNo.�SPOdlZ9�1 Date !I/��!(c�
*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