2017_0302 � _ _ - - � .___.._�_ .
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 PERSONIPHONE:
LOCATION OFSERVICE: NS S r�•
The backflow pmvendon assembly detailed below h s been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
R uced Pressure Principle "Reduced Pressure Principle-Detector
oubleCheckValve 'Double Check-Detector
PressurcVacuumBreaker 'Spill-Resistant Pressure Vacuum Breaker
Manufacturer ' L Model Number �� Size � ��
Located At �,rd►�T -( Serial Number �_�5
ls the assembly installed in accordance with manufacturer recommendations and/or local codes? -GS
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
� Relief Valve Air Inlet Check Valve
� I st Check 2nd Check
� Held at�ps' eld at Z-�� psid pened at Opened at Held at
Initial Test Closed Tight : Closed Tight a-� psid psid psid
� Leaked`i Leaked id not open ! Did not open ' Leaked
� Repairs/
� Materials
� Used
Hetd at psid Held at psid
� Test After Opened at Opened at Held at
Repair ClosedTight': ': ClosedTight psid psid psid
3
�
t
� Test gauge used:Make/Model SN: �Z13ZSG5
! Date Tested for Accuracy: 4-l2�17
I Remarks:
The above is certified to be true at the time of testing.
FirmName Tl Firm Address C'�• �? S r �1�
�
Certified Tester(print) Certified Tester(signature)
Firm Phone# Z- Cert.Tester No. ����`�Z ate �'Z'/'I
"TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
j ' �"�USE ONLY MANUFACTURER'S REPLACEMENT PART5
�
� White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy
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