2017_0609 IRRIGATION DOMESTIC FIRELINE
The following form must be completed for each assem ly 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 1.D. # 0570040
(Customer)
MAILING ADDRESS: �G • �. ' � �� � 5����
CONTACT PERSON/PHONE: ` 1 ' �� (A � U
LOCATION OF SERVICE: � � � � s'�� "
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-Detector
�� ��Double Check Valve �Double Check-Detector
PressureVacuumBreaker -Spill-Resistant Pressure Vacuum Breaker
� l�l�.!" �' '(
Manufacturer Model Number �� � S(,T�=Size
Located At Serial Number���� ����_
Is the assembly install d in acco 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�psid Opened at� Opened at Held at
Inirial Test Closed Tigh Closed Tight � psid psid psid
Leaked� I Leaked� I, Did not open Did not open � Leaked' I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Hcld at
Repair ClosedTight,: ClosedTight psid psid psid
Test gauge used: Make/Model rV��C�V.1 Q.�� SN:����n �-�� �
Date Tested for Accuracy: � �� —"� ��
Remarks: \.Q-S �'�o
Th above is certifi to be true at the time of testing. �
��y�p-Z-a n`a� ��,�"�`` _ �ir"` , ✓�
N ....,
FirmName���•�(�,�'�S�-F.,�A� Firm Address � � t� �1 7(�,f�O2
, {
Certified Tester(pr�nt) � � 1�� Certified Tester(signature) � -
Firm Phone#�,�? "���` 03�Cert.Tester No.��a���S 1 Date �[j"7 '" ��
* 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