2016_1228 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: � ✓
LOCATION OFSERVICE: � ,3 iL?� �',�'I�flV�e
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
�R uced Pressure Principle —Reduced Pressure Principle-Detector
�ouble Check Valve � �Double Check-Detectar
❑PressureVacuumBreaker iSpill-Resistant Pressure Vacuum Breaker
Manufacturer �1 ��r7 Model Number ��� Size
�
Located At Serial Number���/���
Is the assembly installe in accordance ith 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
���f�� Held at��psid Held atZ� � psid Opened at Opened at Held at
Inittaf est Closed Tightl� Closed Tight � psid psid psid
Leaked' 1 Leaked� Did not open _� Did not open � I Leaked��.7
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight,- ClosedTight'� psid psid psid
Test gauge used: Make/Model /���� ��a������U SN: � 3��L���pC,�
Date Tested for Accuracy: � � '��
Remarks:
The above is certified to be true at the time of testing.
Firm Name iLff ' f"-�'�n Address,'J'�6� �l���Y'%� /r�
��
Certified Tester(pr�nt) P Certified Tester(signature)
Firm Phone#"/��` ����� Cert.Tester N Date � �
* 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