2016_1107 IRRIGATION DOMESTIC FIRELW E�
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: "�5�
CONTACT PERSON/PHONE: L��.�.� , ��y a�o �t
LOCATION OF SERVICE: 1 K t� L►be.1t- .
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
�Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qt.,1t� Model Number�,�p�h$ Size 1�
Located At Serial Number {�F1� �E,�
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 Iniet Check Valve
]st Check 2nd Check
Held at�ps Held at�,b psi Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairsl
Materiais
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model�� �{O-2�iC�j-+kJ`-�.� SN:Q j l4 2YCc�
Date Tested for Accuracy: SfN_,f!(�
Remarks:
The above is certified to be true at the time of testing.
Firm Name.l�,o�•.o.,�1x.c.1L F�s �?�u�. Firm Address t�0 . 2��_Wn`�1�+ar�t_?X �6`b
Certified Tester(print)�1�,.�� Certified Tester(signature) �
Firm Phone#2j'�,�IN.3t�'�I Cert_Tester No.BPOt�lL9yS Date�$�(4a
�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