2016_1107 IRRlGATION 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:�$���y.q�p. �yq 3
LOCATION OF SERVICE:jQ3a �.o�,,.�1,•�.,�e
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 �7Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufachuer �
Qt.,�{� Model Number�rnCX�� Size 1
Located At Serial Number � (o l a�
Is the assembiy 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 ato�.�' psi Held ata�•� psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight psid psid psid
Leaked❑ Leaked❑ Did not open Q Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held aY
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model�l��p-ZQa-�kjr�. SN:�[y2�lc'}
Date Tested for Accuracy:�'f+�(!n
�
Remarks:
The above is certified to be true at the time of testing.
FirmName.l.��,..Qr,�tx,c� F�c �c�u�, Firm Addresst�f��• �'��- �A�.-M�.,..�1,�-� '� �(,�
Certified Tester(print)�1��,`� Certified Tester(signature)
Fum Phone#2.1'�,�L�{N,3tR'�I Cert.TesterNo.3POOlL9yS Date l�'}�1(r�
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**LJSE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yeliow-Custorner Copy Pink-Tester's Copy