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: � "�{'
CONTACT PERSON/PHONE: z1
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 Ql.r.r� Model Number�[��� Size !�
Located At Serial Number �'S �� 7
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 b,'b psid Held at�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
�4� ( Leaked❑ 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 Closed Tight❑ Closed Tight 0 psid psid psid
Test gauge used:Make/Model�pl��0-Z�,�Cj-�-�GJ��, SN:Q+i 142�lc�
Date Tested for Accuracy: 5 *�!/l(F,
Remarks:
The above is certified to be true at the time of testing.
Fum Name��c�•.a.,�1�0�� F�i ��u�, Firm A ddress t�� ,�.� m1� � � �b`�
Certified Tester(print)�1�,.,�a�Certified Tester(signature) �
Fum Phone#2.1'�,+�L�I�I,7vlR�I Cert.TesterNo.3POQlZ-�fi`IS Date [T�1 to
*TEST RECORDS MUST BE KEP'T FOR AT LEAST THREE YEARS
**iJSE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy