2017_1230 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: ' ' �
CONTACT PERSON/P E:
LOCATION OF SERVICE: -_. �.�`
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters. �
TYPE OF ASSEMBLY
�Reduced Pressure Principle �'Reduced Pressure Principle-Detector
����DoubleCheckValve ���Double Check-Detector �
'�_PressureVacuumBreaker -'�Spill-Resistant Pressure Vacuum Breaker
Manufacturer - Model Number Size
Located At Serial Number -
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 a± = - O}�ened at Held at__
Initial Test Closed TightF�` Closed Tight �� � psid psid psid
_ Leaked ,' Leaked� Did not open i Did not open Leaked I
Repairs/
Materials _
Used
Held at_ psid Held at psid
• Test After Opened at__ Upened at Held at
Repair Closed Tight����1111 Closed Tight.! psid psid psid
Test gauge used: Make/Model� SN:_
Date Tested for Accuracy:
Remarks:
Tbe above is certiiied to be true at the time of testing.
FirmName � Firn1 Address "
Certified Tester(print) �� � Certified Tester(signature)�-��� �
Firm Phone# • � � � Cert.Tester Na � � � 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 Cop}c