2017_0328 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: / (�'t,�
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-Detectar
�d•Double Check Valve �Double Check-Detector
'PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer (�c��7 �r.�s Model Number �3 ,�� Size�
Located At ����� � �/j�./L� Serial Number��a�,� �I�i �
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t� �
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held a��� psid Held at�r/Z psid Opened at Opened at Held at
Initial Test Closed Tight�r 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�� i Closed Tight � psid psid psid
�
Test gauge used: Make/Model Gc,�+r/Sit¢c p �v�-avr� / �j v SN: � f��lG R �
Date Tested for Accuracy: ����j �c (O
Remarks:
The above is certified to be true at the time of testing.
Firm Name��� .��2 Firm A ddress L�i�,2 �s'/1�'r�r.� J/,�/�SC �
Certified Tester(print)/'Ylre � ��L` Certified Tester(signatur��������� �"'vC�i�
Firm Phone#�7aZ��l�fJ—�-�7 3�Cert.Tester No. �S �D Date d ��
* 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