2016_1102 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 LD. # 0570040
(Customer)
MAILING ADDRESS: �' L �1 -{''r�
CONTACT PERSON/PHONE: " � �
LOCATION OF SERVICE:
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
iRe Pressure Principle -1Reduced Pressure Principle-Detector
� I ouble Check Valve �Double Check-Detectar
:1 Pressure Vacuum Breaker I Spill-Resistant Pressure Vacuum Breaker
a7�� ` s� ('��'� � 3
Manufacturer '1�'�"—��J Model Number_��1" ''� �✓ Size J
Located At Serial Number ��.J � �� �
Is the assembly i stalled in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valv Air Inlet Check Valve
1 st Check 2nd Check
Held at C �psid Held a,t�psid O ene t Op at at
Initial Test Closed Tight�� ]osed Tight I,� p d d � psid
Leaked. I Leaked-.I Did open I D d no open ' I d''
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight l ClosedTight.l psid psid psid
�'
Test gauge used: Make/Model ���c1�t� ��Z�� SN: � 2�c ��+ Z,
Date Tested for Accuracy: � � �� �� (
Remarks:
The above is certified to be true at the time of testing.
Firm Name ��'��/����irm Addres$
Certified Tester(print) � `� �'' �� � ertified Tester(signature)
Firm Phone# �`�� �� � Cert.Tester No. � Date d� ���` �
* 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