2017_0228 � FIRELINE
IRRIGATION DOMESTIC
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�' ' #� �i ��x ��C)/
CONTACT PERSON/PHONE: - �A� Z `• �b'
LOCATION OF SERVICE: I
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
❑�uced Pressure Principle �Reduced Pressure Principle-Detector
f�'DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
� `� r�i�
Manufacturer Vw�� Model Number ���I� Size oC.
Located At �O�f IjfS�'�CI�i����b� IN���(�- Serial Number ���
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ' U�
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 o5���ps' Held a��Q psi Opened at Opened at Held at
Initial Test Closed Tight�� Closed Tight f 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�� Closed Tight f 1 psid psid psid
{ Lr ��
Test gauge used:Make/Model Vv�t �� �� SN: ���d-���1
Date Tested for Accuracy: l `
Remarks: U,A.��� � !J ,►gl � - �
The above is certified to be true at the time of testing.
�.—'' ['` n�--
Firm Name �I�'�, ( � t� Firm Address ��l� 4--l�1F�'��'! �x��
/
Certified Tester rint���; �
(p � �� Certified Tester(signature)�—�
Firm Phone# ��1��������� Cert.Tester No.(.� ���n� Date � �� j
*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