2016_0603 IRRIGATION V 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: C> GZ(6Q 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
�R duced Pressure Principle -Reduced Pressure Principle-Detector
ouble Check Valve - Double Check-Detector
PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer Gvc G.�It•✓� Model Number 3S� Size�
Located At l�����{�/� Serial Number/'��`�'S� 70�
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�^�5 psid Held at�"� � psid Opened at Opened at Held at
Initial Test Closed Tight�� Closed 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 � ps�d psid psid
Test gauge used: Make/Model fo�n�li4�' �lD�1�.�u f frv sNC�C�o� r G � -�
Date Tested for Accuracy: � t /S�
Remarks:
The above is certified to be true at the time of testing.
Firm Name,S/.� ..���� Firm Address�li�.Z �SII/`�G��rs S�i �'�5C ��/
CertifiedTester(pr;nt)�'!'1i���,•.L ,��h�;-CertifiedTester(signatur -,�� �� ��
Firm Phone#�7���j��— � �-j 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