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. #0570040
(Customer) _
MAILING ADDRESS: ��
CONTACT PERSON/PHONE•�n,�,� �ty �130 cr�R 3
LOCATION OF SERVICE: �c1�c 1 �tn��eL���P
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to he operating within acceptable parameters.
TY�E OF ASSEMBLY
�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�dDouble Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer pt,r.�,� Model Number�CMX+�� Size 1�
Located At Serial Number ��o� �.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 aY��ps- Held at��psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight'B� psid psid psid
Leaked❑ Leaked0 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:Make/Model��M �j0-2�-�-�cJ��. SN:�{t�2�6lc�
Date Tested for Accuracy:���I/l L.
Remarks:
T'he above is certified to be true at the time of testing.
FirxnName,�iw�•.��boc.ac_ ��� �e�-�r�. Fnm Address�Q� ��.U►1��1„�c1�t _Tif_ '}�b`d
Certified Tester(print)�1�...�Ib�- Certified Tester(signature)
Firm Phone#21'�,�t�-1'�I.7v19'� Cert.Tester No.k�'iPOOlL9yS Date�1�}�1(0
*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