2017_0109 I RRIGATIO
N DOMESTIC FIRELINE V
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) /1_ O r ^ � T �� ,
MAILING ADDRESS: ��0 �-f.1.1 �
CONTACT PERSON/PH E: 1 '
LOCATION OF SERVICE:
The backflow prevention assembly detailed be ow 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 r�Reduced Pressure Principle-Detector
�QDouble Check Valve �Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer W� 1 Size�
(,d Model Number
Located At� �lT ►`L�� ��J Serial Number ���
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 1�fj
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 psid Held at psid Opened at Opened at Held at
Initial Test Closed Tight�J Closed Tight � psid psid psid
Leaked❑ Leaked�7 Did not open ��� Did not open ❑ Leaked❑
Repairs/ # !�b�i �p�Xi��� "'rV✓l �(�1 ll'�.i ��if'�(�
1
Used ials �`��jL ��j5� l��t�J� �'Lt'�F��
\ �
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight��� Closed Tight�! psid psid psid
� ,{ ,,
Test gauge used: Make/Model t�l�$ � � SN: ��� '�"Lv�
Date Tested r�F uracy: ��
Remarks: �� :. h t �D � I�t�
The above is certified to be true at the time of testing.
� �„��j �U J'�t9 Firm Address � 00'�
Firm Name ��C•
— .�'
Certified Tester(print) lFi{/ � Certified Tester(signature
Firm Phone# L�� �� '� � Cert.TesterNo. ����� Date 7
* 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