2016_0613 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: ?�'j� �..v L l rv� pv�'✓
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
1 Reduced Pressure Principle -Reduced Pressure Principle-Detectar
,l�Double Check Valve - Double Check-Detector
' 'PressureVacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker
3
Manufacturer(,�i�i�r��v5 Model Number �S73 Size�
Located At ��v�/��/14/� Serial NumberJ�'S��/�a� �'}' �
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 a�` � psid Held a��� psid Opened at Opened at Held at
Initial Test Closed Tigh�1�- Closed Tight �ci' psid psid psid
Leaked� I 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 ClosedTight�� ClosedTight '� psid psid psid
Test gauge used: Make/ModelCom isl2qC0 KO-aatJ- �h v SN:�' ��-/ �(o �i �
Date Tested for Accuracy: 9 /�/j
Remarks:
The above is certified to be true at the time of testing.
FirmName ,�� -�� Firm Address(o��a �'45'�V���,��v �i^�r6fS� '�f{i'
Certified Tester(print)j��C!./-/}�� ��u�P�tls Certified Tester(signature) ���
Firm Phone#��,�� �'�'G-3�3 �-/ Cert.Tester No. �$r�JU 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