2016_1128 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: `i rv �
LOCATION OF SERVICE: S �,
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
' uced Pressure Principle iReduced Pressure Principle-Detector
� ouble Check Valve -!Double Check-Detector
1PressureVacuumBreaker :-�Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �� l k�v+S Model Number 3Sd Size /y r ,
/
Located At �vc��-' ��1 Serial Number !¢6U�C��
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 �-v psi 'Held at Z�`1 psi pened at Opened at Held at
Initial Test Closed Tighti�� Closed Tight � � psid psid psid
Leaked' I Leaked' ' Did not open ' Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight' Closed Tight .' psid psid psid
Test gauge used: Make/Model !`/��'�1r9 SN: �Z/3�565
Date Tested for Accuracy: `'1-I�-!�
Remarks:
The above is certified to be true at the time of testing.
Firm Name ��v��� Firm Address � " �'�� ���SS �- �7� ��I
Certified Tester(print) � � Certified Tester(signature) �
Firm Phone# ���'�$� Cert.Tester No. !N'���Z Date %�-Z�S-�.�
* 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