2017_0625 IRRIGATION � DOMESTIC FIRELINE
The following form must be completed for each assembly tested. A signed and dated original J"
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:
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 1Reduced Pressure Principle-Detector
�ble Check Valve 'Double Check-Detector
�]PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer �� Model Number /� J V 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���psi e d a��psid Opene at en d at eld at
Initial Test Closed Tight��� � Closed Tight � � psid sid
Leaked��' Leaked'�. ��� Did not o en � ot open ed ��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight���� ' Closed Tight.I psid psid psid
Test gauge used: Make/Model��/t'l�� ��`"� SN:_� CJ��1"'L�f
Date Tested for Accuracy: �'�2���
Remarks:
The above is certified to be true at the time of testing.
FirmNam� Firm Address
Certified Tester(pr;nt) � Certified Tester(signature)
Firm Phone#�� �'� �v Cert.Tester No. � � 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