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:
The backflow prevention assembly detailed below has been tested and maintained as reGuired 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 ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer A„�« Model Number�_C�$ Size l�
Located At Serial Number 6 5�(�.2
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 Inlet Check Valve
lst Check 2nd Check
Held at a•� ps' Held at�psid Opened at Opened at Held at
Initial Test Closed Tight Closed Tight C� psid psid psid
Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model�ln,��j �{0-2�-+�:Jr�. SN:�lyZ��C'}
Date Tested for Accuracy: 5 �i/l �
Remarks:
The above is certified to be true at the time of testing.
Firm Name,L��..•.o,,,��c,c„� Fi�s 'P�,�-,w, Firm Address t��$o�c�Ub.����L••� �(, �d�
Certified Tester(print)�1�..,�a f�Certified Tester(signature)
Firm Phone#2l'�,'iHH.319�-1 Cert.Tester No.�POOlZ9`�S Date /��!(o
*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