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 REP4RT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: '�'S�
CONTACT PERSON/PHONE:�������y �130 �^A
LOCATION OF SERVICE:�3�i L�behti,
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 ❑Double Check-Detector
❑FressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qt,.1E� Model Number 2C�X�?$ Size I�`
Located At Serial Number � 3`�O �o
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressute Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assemb(y
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at`�ea ps' Held at�_psid Opened at Opened at Held at
Initial Test Closed Tigh Closed Tight B� 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/Model�� �{O-2€lC�-�CJr�i SN:QH t y Z��c'}
Date Tested for Accuracy: 5�,1���
Remarks:
The above is certified to be true at the time of testing.
Fum Name.t�,o�...p��ba.,�1L �Fs ���Firm Address t�b�,c Z��.U►_1s,�1r+a��TX �a 6`b
Certified Tester(print)����Ie�- Certified Tester(signature)
Firm Phone#21'�.�1;I�1,3t'�t`�1 Cert.Tester No.3POC�lZ_9'#S Date (���f to
*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