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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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: � �`^ o� �o r
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 lReduced Pressure Principle-Detector
�pouble Check Valve 'Double Check-Detector
PressureVacuumBreaker lSpill-Resistant Pressure Vacuum Breaker
��
Manufacturer Wi�,�S Model Number �.�OOZ1►'�3 dZ Size�
Located At Iv el�'k '�U M�'f'� Serial Number O`LZ�
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 at Opened at Held at
Initial Test Closed Tight'j� Closed Tight 1� psid psid psid
Leakedl I Leaked' ; Did not open __ Did not open Leaked_ �
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight 1 ClosedTight[ psid psid psid
Test gauge used: Make/Model �4�'.� �CS� ��� SN: �s�7��9 y
Date Tested for Accuracy: $'�2 ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name �� �'T l-0 � 1 Firm Address a �� S� �� c�� � ?$�(9
Certified Tester(pr�nt) �0�� �•M�� Certified Tester(signature)
Firm Phone#�7 Z'�,�2'��.�� Cert.Tester No.1,�1 OD I1.�1� Date � 2� �g
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy