2017_0403 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:
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
�rlReduced Pressure Principle �lReduced Pressure Principle-Detector
❑Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer "�► � �� `/j � � �7�
Model Number Size�_
Located At L��i' b�'Q f Serial Number � � � �
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� Closed Tight !� psid psid psid
Leakedf ; Leaked�.,� Did not open f�� 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!�I psid psid psid
Test gauge used: Make/Mode1��1�1�� ��Q�'J4/ ;���C� SN: ����1 J J��
Date Tested for Accuracy: _���/'7���
Remarks:
The above is certified to be true at the time of testing.
FirmName��)�/"IU-U,���G ��l����G�,'` Firm Address ,;�fJf�O'�i ��t�� �(;�j�I�j1,I�X'7S�Gr�/
� � �
Certified Tester(print)��������_Certified Tester(signature) ��iy��
�
.� � j �
Firm Phone# �'7������.�����j Cert.Tester No. 'j,���j��� 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