2017_0505 IRRIGATION DOMESTIC FIREIINE
The following form must be completed for each assembly tested. A signed and dated original
must be submitted to the public water suppiier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS t.D. #OS'70040
(Customer}
MAtL[NG ADDRESS:
CONTACT PERSON/PHONE: o
LOCATION OF SERVICE: �.$D T �� �'Nc G
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.
r
TYPE OF ASSEMBLY
uced Pressure Principle Reduced Pressure Principle-Detector
oubleCheckValve Double Check-Detector �
PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer �n/,I �w5 Model Number 3�� Size 3 ''/"
Located At 1'�ew� Z'.n/� _Serial Number �63025� ��
Is jhe assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly Relief Vaive Air Inlet Check Valve
1 st Check 2nd Check
Held at .�� .ps' Held at�-1.p ' Opened at Opened at Held at
Initial Test Closed Tight Closed Tigh ps�d psid psid
Leaked Leaked ' Did not open 1 Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid Opened at Opened at Held at
Test After
Repair ClosedTight ClosedTight ' ps;d psid psid
Test gauge used: Make/Model �l10�� sN: izr;z�b5
Date Tested for Accuracy: 3 �-( 1 g —
Remarks:
The above is certified to be true at the time of testing.
Firm Name_ Firm Address L� �
Certified Tester(print} Certified Tester(signature)
Firm Phone# " — Cert.Tester No. �t Date s-5—�1
'�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