2017_0518 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: ��5 ���-n�1�-� � ^ �p n��� �� ��� � �
CONTACT PERSON/PHONE: ^ oS O(1
LOCATION OF SERVICE: �j� � � �
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
�educed Pressure Principle Reduced Pressure Principle-Detector
ouble Check Valve �Double Check-Detectar
1PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
�-�.1.� �—1$��-- Size L 1 I
Manufacturer Model Number
Located At ���J`.��"��- Serial Number � � � � �1 �
Is the assembly installed in accordance 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�psid Opened at� Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked I Leaked I 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 �1,o C��-� � SN: �� `�0 0���_�
Date Tested for Accuracy: ' �- `"
Remarks:
The above is certified to be true at the time of testing. �
F�rm Name �
Firm Address � O � I\ ��
a� �� �a� 1��.:5 ° _ - -� �r�
Certified Tester(print) �e�. � ��1(:� , ertified Tester'(signature)
�_
Firm Phone# �gZ ��.3�'��� Cert.Tester No.��O~� /r` Date �� � ��
* 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