2017_0306 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: �'oaj��„
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
�Reduced Pressure Principle �Reduced Pressure Principle-Detector
�oubleCheckValve ��IDouble Check-Detector
❑PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
Manufacturer�,, �� �l�i�JS Model Number___ �s d Size 1 r�
Located At Serial Number/��i`��'Z 3
Is the assembl � stalled 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��S psid Opened at Opened at Held at
Initial Test Closed Tight�_ Closed Tight� psid psid psid
Le�aked�, 1 Leaked'�1 Did not open ;�1 Did not open [_I Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight�7 Closed Tight�J psid psid psid
Test gauge used: Make/Model ry1.G �4�" S SN://Dl O�$
Date Tested for Accuracy: !�l�!7
Rernarks:
The above is certified to be true at the time of testing.
FirmName K��-�J�f} Firm Address� 1� �W�� ��
D �7�z�
Certified Tester(print�e..� t�� Certified Tester(signatwe)
Firm Phone#� 3(9��c'�_Cert.Tester No.�ID o1�3 D Date 3 --�_
* 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