2016_1107 IRRIGATION DOMESTIC FIRELINE�C_
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: �
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
�DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Presswe Vacuum Breaker
Manufacturer �„�� Model Number 2QjC�$ Size l�
Located At Serial Number ��o�O�
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 psid Held ato�o� 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
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight t7 psid psid psid
Test gauge used:Make/Model�`p �p-?�lb-�kJr�. SN:�t y 2YCc�
Date Tested for Accuracy: 5'f��
Remarks:
The above is certified to be true at the time of testing.
Firm Name1��•,Q,�bc,c� F�� ��,�c��r,�, Firm Address t�� 2_��UJ��.1���t�„ �6$
Certified Tester(print)�1�..'��(t,r_Certified Tester(signature)
Fum Phone#21'�.�N-I�I.7vtR'�1 Cert.Tester No.3PQ�lZ9�1S Date P(���lGy
*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