2016_1105 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 far 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: D ��
LOCATION OF SERVICE• �T� � �Cl �L Ol/,2�
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
�ouble Check Valve I Double Check-Detector
1PressureVacuumBreaker f7Spill-Resistant Pressure Vacuum Breaker
, �7 r�
Manufacturer '�/1,�i �. ��I 11� Model Number �5�� Size�
Located At �!1 Gcl� Serial Number����-`�.��
Is the assembly installe in accordance with manufacturer recommendations and/or local codes? �
Reduced Pressure Princi le Assembl Pressure Vacuum Bre ker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
P,��,S�j.Q� Held at�• � psid Held at��� psid Opened at Opened at Held at
Initial Test Closed Tightl ', Closed Tight i- psid psid psid
Leaked'���I Leakedl! Did not open ❑ Did not open [.I Leaked'�.
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightl ` ClosedTight�� l psid psid psid
Test gauge used:Make/Model ���_�-����Ks u SN: b �j�a� ��p�'
Date Tested for Accuracy: � �o' ��P
Remarks:
The above is certified to be true at the time of testing.
Firm Name ��' ( �(rl �,�I� Firm Address �d � � �
� �
Certified Tester(prir�t) li' 1'� Certified Tester(signature)
Firm Phone# �� �``���,� ��� Cert Tester No. � � � Date �l l
* 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