2016_0627 IRRIGATION V 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: 7 .`� l.t�S 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.
TYPE OF ASSEMBLY
� ���Reduced Pressure Principle �Reduced Pressure Principle-Detectar
�+I'Double Check Valve Double Check-Detector
iPressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer Ztlt��?(ir� Model Number —��� Size ��
Located At `�/20�1 �//'��� Serial Number/T J�7o� �Y �! L/
Is the assembly installed in accordance with manufacturer recommendations and/ar 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 atL� / psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight�' Closed Tight � psid psid psid
Leaked ' 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 I Closed Tight psid psid psid
Test gauge used: Make/Model Cvan+6iCq-tp �I!�•-.l�•v�fi u SN:Q�,pt-� t f> `�j 7
Date Tested for Accuracy: �'l!!�� �^
Remarks:
The above is certified to be true at the time of testing.
Firm Name �/3 `.�/2� Firm A ddress f�G�.2 �,�S 7 i/��/ ,�'�C�� ��
CertifiedTester r�nr �� uel�i(;CertifiedTester si natur ���� �l��
�P ��— � ( �g ,� ,
Firm Phone#q7����.� - 3 73� Cert.Tester No. a ��� Date l.2'
* 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