2016_1107 IRRIGATION DOMESTIC FIRELIIVE�
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
(Customerj .
MAILING ADDRESS: "�'�
CQNTACTPERSON/PHONE: �,r�p ,��y.�t'�O, c�H 3
LOCATIOAT OF SERVICE: 1bl1 �r.ae�elc,�^p
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
�'DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qt.,�,.�� Model Number�(�h�5 Size !H
Located At Serial Number I� t3 i
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
Heid at��psid Held at a-� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materiais
Used
Held at psid He}d at psid
Test ARer Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Testgaugeused:Make/ModelAr�r,t�p �0-2-�1D��G��, SN:�{ly2��c'}
Date TestedforAccuracy: Sfif,/l�
Remarks:
The above is certified to be true at the time of testing.
Firm Namel��o....��bo,c� F�� ��e�}��Firm Address t'�b 2—�7`J�U��oo.l�,nsl,..�T� �b�
�
Certified Tester(print)Z1�..,"`��I.�r- Certified Tester(signature)
Firm Phone#2i+1,'�LN�1,319'-� Cert.Tester No.3�ll9�IS Date /��1 fo
*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