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. #057004Q
(Customer) ,
MAILING ADDRESS: �'�
CONTACT PERSON/PHONE•�n,�,�p �ly q'$O �A 3
LOCATION OF SERVICE: tO�.S =.,ato �M�p
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
. TYPE OF ASSEMBLY
❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector
�boubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qt„�.r� ModelNumber�,C�CX�1$ ___Size I�
Located At Serial Number �5`� -�7
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 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❑ psid psid psid
Test gauge used:Make/Mode1�M��� �O-2�lU-�C'$►, SN:�ly2��c�
Date Tested for Accuracy: Sl'��I/l t�
Remarks:
The above is certified to be true at the time of testing.
FirmNameJ�a�„�bac� -fi�e. ��,rri, Firm Addresst�� . �h�. ,00.L,acl.�sr�. �b�
Certified Tester(print)''�1�...��Certified Tester{signature)
Firm Phone#21'�.'�N'�1.3tR�1 Cert.Tester No.3P��19`� Date f��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