2017_0206 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 OF SERVICE: t c�-�r'1 Q
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
�Reduced Pressure Principle Reduced Pressure Principle-Detector
`.Bouble Check Valve Double Check-Detector
Pressure Vacuum Breaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer �[� Model Number ��� " Size �
Located At ��-� Serial Number�����j �
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�psid Held at�psid Opened at Opened at Held at
Initiat Test Closed Tight� � Closet�l�Tight ; '�� psid psid psid
Leaked ' 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�j,rl.f� SN:
1'Z�t3�?�
Date Tested for Accuracy: '� ��L �� L
Remarks:
The above is certified to be true at the time of testing.
Firm Name� �'���%"'�J"iF'irm Address � � � ��'�
Certified Tester(print) �`�- � Certified Tester(signature)
Firm Phone�R�� �� �� Cert.Tester No.���� Date �""�� � I �
* 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