2016_1107 IRRIGATION DOMESTIC FIRELINE_1�
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: C � "}6
CONTACT PERSON/PHONE: q
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 ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
:�PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Q1.,��� Model Number�Cnoc�$ Size (n
Located At Serial Number (3 Si/0 3 �
Is the assembly installe in accordance with manufacturer recommendations andJor 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 Tight� 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 Closed Tight❑ Closed Tight❑ psid psid psid
Testgaugeused:Make/ModelQ�r,r,��j yb-Z�-+�CJr�_� SN:�I�{2Y�c�
Date Tested for Accuracy: 5,/,�l/1�p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��a�..s►,o�loa�ti -ri�e �c�es��c�, Firm Addresst�f�$c,c ?�� � �, �516�
Certified Tester(print)�1�..,�aT��- Certified Tester(signature)
Firm Phone#21�1.�{�1�1.319�-1 Cert.Tester No.�iPOOlL9yS Date 1 I���1(0
*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