2016_1031 i
IRRIGATION DOMESTIC FIRELINE
The following tarm must be completed for each assembly tested. A signed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTIOIV ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CCTY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: �
LOGATION OF SERVICE:
The backflow prevention assembly detailed below as een teste�'9�id maincained as required by
commission regulations and is certifted to be operating within acceptable parameters.
TYPE O�ASSEMBLY
ced Pressure Principle ;Reduced Pressure Principle-Detector
ouble Check Valve ! !Double Check-Detectar
'?PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker
Manufacturer � ����s Model Number ,�'� Size 3 y"
Located At �.s..�-`h�Jl Serial Number���
Is the assembly installed 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
1 st Check 2nd Check
Held at�psi eld at�ps' Opened at Opened at Held at
Initial Test Closed TightC: Closed Tight . psid psid psid
Leakedi � Leaked` ! id noC open '.; 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 Closed Tight ) psid psid psid
Test gauge used:Make/Model SN: �Z 13 ZSGS
Date Tested for Accuracy: �'�"'�2-19
Remarks:
The above is certified to be true at the time of testing.
Firm Name . � Firm Address � �� r"""""
Certified Tester(print) Certified Tester(signature)
Firm Phone# Cert.Tester No. te�-��,/—�_
*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