2017_0313 (2) 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: I �� � 1 � � PI�(/�[L_� � C OD � ���� �
CONTACT PERSON/PHONE: —42. �"�
LOCATION OF SERVICE: � � �+ y'V� �
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
�j�Reduced Pressure Principle Reduced Pressure Principle-Detector
��`DoubleCheckValve �Double Check-Detector
: iPressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
I � '
Manufacturer Model Number � � �� � Size
Located At f� Serial Number �j 1���p� � �
Is the assembly installe in accor ance 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 /'p sid Opened at� Opened at Held at
Initial Test Closed Tight� Closed Tight� 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 Closed Tight_ ' Closed Tight psid psid psid
, ,..�...
Test gauge used: Make/Model m� �,��I SN: ��` �3� �
Date Tested for Accuracy: J — �� — � �p
Remarks: � �S\ �p�C�
The above is certified to be true at the time of testing.
Firm Name Firm Address � �� (}'� � �
...�-
. -� � lfl�
Certified Tester(pr;nt) • `Certified Tester(signatare)
Firm Phone# V��,� '�3`�"✓_�"!� Cert.Tester No.�/7O�I I �S�f 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