2016_1107 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: '�S'
CONTACT PERSON/PHONE: at
LOCATION OF SERVICE: b(9
'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 ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Q1,,,��� Model Number�C�CX7$ Size lN
Located At Serial Number (��$lo�
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at�.� �/p� Held at�psid Opened at Opened at Held at
Initial Test Closed TightlJ Closed Tight � psid psid psid
Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:MakefModel��lr,r,��j y0-ZOC�-��GJr�. SN:�ty 2�fo"}
Date Tested for Accuracy: Sf��
Remarks:
The above is certified to be true at the time of testing.
Firm Name.l��ar.,��bo,c� -r,�c ��-,e�, Firm A ddress t���enc�1A1n��.L,as�-!TX '�b$
Certified Tester(print)�1����- Certified Tester(signature)
Firm Phone#2l'�.'�1�1�1.319�-I Cert.Tester No.�POOlZ9�IS Date lT�/I!o
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANLJFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy