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 C'�_
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
1Reduced Pressure Principle Reduced Pressure Principle-Detector
-J u le Check Valve � Double Check-Detector
IIpressureVacuumBreaker 'Spill-Resistant Pressure Vacuum Breaker
Manufacturer �`��� Model Number G' --J � Size �
Located At 1��-- Serial Number f�yC� I � Z-
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 Tight osed Tight� psid ps�d ps��
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 /L�� SN: ��������
Date Tested for Accuracy: � ''2� ���
Remarks:
The above is certified to be true at the time of testing.
Firm Name � ���_Firm Address f'�3 � '��
�
Certified Tester(print) � ��' Certified Tester(signature)
Firm Phone# �'" � � ��d Cert.Tester No. 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