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: ''S�!'Z � ��� �
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
:i Reduced Pressure Principle 'Reduced Pressure Principle-Detector
��ubleCheckValve -�Double Check-Detector
PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��7 Model Number �� Size_�_
Located At �-�— Serial Number\ ��� ��I�
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
Initial Test Closed Tighh � Closed Tight . I ps�d 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 ClosedTight ClosedTight psid psid psid
Test gauge used: Make/Model__�/���;.� �tIZG� SN: 1�2C?'��v\�
Date Tested for Accuracy: � � "' � �
Remarks:
The above is certified to be true at the time of testing.
Firm Name � �az��''`�J y Firm Address ��� ✓��� Y�
Certified Tester(prinr) � �"'^ Cerrified Tester(signature)
Firm Phone# ���� �� � Cert.Tester No. EJ" �� 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