2016_1018 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: � �5�
CONTACTPERSON/PHONE:�n,�,���y.41�7. trA
LOCATION OF SERVICE:�p L�R T.�lr n�. �r,�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 Ql.,1�� Model Number 2�$ Size la
Located At Serial Number i 3 9 0 3
Is the assembly installe in accorda.nce 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�_psid Held at( •� 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/
Materials
Used
I�eld at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model,����{t�-2.QC�-�F-kJr�, SN:�l y 2�fc'}
Date Tested for Accuracy: Sf�p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel��•.�,�bo,,e� F�,�e. ��s}�Firm Addresst�f� Z�i"��.W�o.,ad�.�ac�.�t_TX �5[b`b
Certified Tester(print)��'�T�r- Certified Tester(signature)
Fum Phone#?��{,�L�l�l.7vlq'i Cert.Tester No.k�PO�lZ9NS Date l��1(�
*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