2017_0627 IRRIGATION V 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 LD. # 0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �' 7 C,vES �¢vc`�'t�
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
�
duced Pressure Principle :-IReduced Pressure Principle-Detector
oubleCheckValve 'Double Check-Detectar
'- PressureVacuumBreaker :Spill-Resistant Pressure Vacuum Breaker
3 E.
Manufacturer d,�Jc�.f j c`v s Model Number ,3 �� Size�
Located At l'�DN� `�/�-rL,� Serial Number � lv'r`�� S�7 y
6
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? L
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 a�` 2' psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight '� � psid psid psid
Leakedl I Leaked� I Did not open . Did not open � I Leaked�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight l Closed Tight ' psid psid psid
Test gauge used: Make/Model C.�n�b�9-Go �U,o�� � �7 C� SN: �(D��-/ l � -�! 7
Date Tested for Accuracy: � �g ( 1 �, —�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �/3 ..,,�/�� Firm Address ��� �i SI 1��ly�✓ �i¢G��' �
�
Certified Tester(print)m���R-�''�— l�v:���ertified Tester(signature ��y�
Firm Phone#�7�` ���'�7�_�Cert.Tester No.���l6 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