2017_0426 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: �,7� �U����/�LC:�
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-Detector
�uble Check Valve Double Check-Detector
'PressureVacuumBreaker 'Spill-Resistant Pressure Vacuum Breaker
3 � `'
Manufacturer (,�c�,h ��S Model Number -3.5�(� Size�
Located At �Ur✓��//�/L/J' Serial Number /� �o� 9��3
�- --,
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � G.=
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'� 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 psid sid
p psid
Test gauge used: Make/ModelComf.���t1� �Z!/,2v� / �i v SN: �lo��( /�oC? �
Date Tested for Accuracy: �/,,2��� (e —�
Remarks:
The above is certified to be true at the time of testing.
�— ^ /
Firm Name ��r�{���� Firm Address • ;��ty 1/�d`�$(Y �
Certified Tester(print)�'yL t��yL�,Dv�L ��Certified Tester(signatur
Firm Phone#�`7 0�-. �J�- 3 �?�Cert. Tester No. ��S 9� Date 'L' �
* 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