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• L'�a:f,�, ��y a3o c� �
LOCATION OF SERVICE: a4 3 L�6e�- .
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
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qt�f� Model Number�[�[�h$ Size lN
Located At Serial Number (����
Is the assembly install in accordance with manufacturer recommendations and/or local codes?
Reduced Presswe Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at��p Held at�,�psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight� psid psid psid
Leaked❑ Leaked❑ Did not open 7 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 Tigbt� psid psid psid
Test gauge used:Make/Model�1� �{O—2.�j—}�J`��� SN:QH ty Z�'�o�
Date Tested for Accuracy:�'!!y!l!p
Remarks:
The above is certified to be true at the time of testing.
FirmName�,o�,..Q�1onc� �« �?�,r,�, Firm Address�'�� Z.S�� . � ,�$ �b$
Certified Tester(print)�1�..,��I�r Certified Tester(signature)
Firm Phone#21'�,y�1�1,31R'�l Cert.TesterNo.BPOOlL9`IS Date���I Ca
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yeliow-Customer Copy Pink-Tester's Copy