2017_0524 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: d �61� p�✓
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �U
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 C-Reduced Pressure Principle-Detector
❑DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �C l�a� Model Number 3S� Size ��'y
Located At Serial Number (p`a / g��
Is the assem ly install d in accorda ce 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 at3 � psid Held at�� psid Opened at Opened at Held at
Initial Test Closed Tight►C¢- Closed Tight� psid psid psid
Leaked�; LeakedG� Did not open ❑ Did not open L 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 �'�`���J` SN:`J8�d���
Date Tested for Accuracy: � l�—� 7
Remarks:
The above is certified to be true at the time of testing.
FirmName aM. Firm Address o��
7 ,Zo�
Certified Tester(print) � ��� ertified Tester(signature) ��.��—��1=,�t�
,
Firm Phone# ���7 f q Cert.Tester No. `C�� Date S �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