2017_0313 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: � _ � � � C O � �,� ����� � �
CONTACT PERSON/PHONE: G I^ $� ' 2 — g�
LOCATION OF SERVICE:
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�educed Pressure Principle :�Reduced Pressure Principle-Detector
'Double Check Valve Double Check-Detector
PressureVacuumBreaker -Spi11-Resistant Pressure Vacuum Breaker
Manufacturer Model Number '� �'
Z-�f�-lV 3'1_�� �, Size
Located At ��l �. _ Serial Number 1�1�O ���
Is the assembly insta ed in acc dance 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�� sid Held at�psid Opened at� Opened at Held at
Initial Test Closed Tight,� Closed Tight ,� psid psid psid
Leaked I Leaked. 1 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 l psid psid psid
Test gauge used: Make/Model (� ( ��5� SN: ����0 �3� �
Date Tested for�cura
Remarks: ,��� _'� �
The above is ce fied to,�true at the time of testing.
�.�v �o�.��..r� � �.5 ���
cU
n �f� �_ �
Firm Name,Ft � Firm Address "( - � O�!� ��l
�
Certified Tester(print) C��, :���d ertified Tester(signatur � �
Firm Phone# ��� '�"3��' �3� ( Cert.Tester No.���d ����� Date 3 —�3 '�
* 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