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. #057004Q
(Customer) .
MAILING ADDRESS: "�-'S
CONTACT PERSON/PHONE: L�r;���� at3�7 ct�A 3
LOCATION OFSERVICE: LbS'� _.•� c� ��P
The bacl�low prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TY�E OF AS5EMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Q,►�.c� Model Number�cnb�n� Size E�
Located At Serial Number �� a?3�
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 a� ps Held at�r�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight C� 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❑ psid psid psid
Test gauge used:Malce/Mode1���J0-Z�jC3-�:'Jre i SN:�l y 2'�fo�
Date Tested for Accuracy: 5�<1�,�
Remarks:
The above is certified to be true at the time of testing.
FirmName, ,o�..Q.,�1�nc� -�'i�e ��r�r�Firm Address���r. 2� �_Wa�.1r+n�],_.-:�(, �5�6`b
Certified Tester(print)�L�..��F�,�- Certified Tester(signature)
Firm Phone#2t'�,�i�i�1.3tR'i Cert.Tester No.13POOlL9'iS Date I���1(c
*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