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
(Customer) .
MAILING ADDRESS: "'�'�
CONTACTPERSON/PHONE:�y;�,8���y.at�0. c�-fl„ 3
LOCATION OF SERVICE:�Q$�_�,�a�c��P_ _
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TY�E OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�DoubleCheckValve ❑Double Check Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qtw�,�� Model Number '�{�t�$ Size lµ
Located At Serial Number 1(oc��S
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��ps� Held at � psid Opened at �pened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked❑ LeakedQ Did not open 0 Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Hetd at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ psid psid psid
Test gauge used:Make/Model�p�`��p-Zf�X'�j-�-�CJ'—�. SN:�{ty 2�fc'}
Date Tested for Accuracy: 5'f1{�(�p
Remarks:
The above is certified to be true at the time of testing.
FirmNamel�rc.f•.a.,�bo,c� F�,�i �d},e�-,on Firm Addresst�f)�c Z�'}_Wo��.4,Qc�r �� �{,$
Certified Tester(print)�l�...'�aT(�_Certified Tester(signature)
Fum Phone#2.1'�.'�4W.3[9'�f Cert.Tester No.k'�P�blZ94S Date f_T�I l�
*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