RPZ_2016_0615 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) n
MAILING ADDRESS: 0 `r �.O e( l
CONTACT PERSON/PHONE: ` ' Z 1 - 4 - O`f�
LOCATION OF SERVICE: 1 �A
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
� f'�Reduced Pressure Principle �1Reduced Pressure Principle-Detectar
�DoubleCheckValve ��� ]Double Check-Detector
�IPressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer WQ-C�5 Model Number �Q/ � I Size ' �Z �/
Located At CUS�o� t�ct,I l.,l�5e"f Serial Number '��9 � 7 I
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��.5
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
Held at��psid Held at psid Opened at Z� Z Opened at Held at
Initial Test Closed Tightl 1 Closed Tight �J psid psid psid
Leaked'� I Leaked�J Did not open I i Did not open I I Leaked� I
Repairs/
Materials
Used
Neld at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight' J Closed Tight'_1 psid psid psid
Test gauge used: Make/Model���,�� t� �O-- 7�DQ�C_ SN: ZS�l�
Date Tested for Accuracy: �/�!�'��J`w
Remarks:
The above is certified to be true at the time of testing.
...� �3 � ,
Firm Name C�,o p�e 1 I L�� Firm Address
Certified Tester(pr�nt) � �� Certified Tester(signature) �
Firm Phone� �7� ' �Q �� Cert Tester No. ��o�S2� Date � �3 ��
* 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