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: T�„LL��r�1'i °�vp �t 3
LOCATION OF SERVICE: �4.� L�
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 OReduced Pressure Principle-Detector
�'Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Q.��� Model Number�,Cn�h�i Size 1�
Located At Serial Number ��?���
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assemb(y
Relief Valve Air Inlet Check Vaive
1 st Check 2nd Check
Held at�r� p Hetd at�psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight psid psid psid
Leaked❑ LeakedG Did not open ❑ Did not open ❑ Leaked�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opeoed at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model�� �{b-Z�1C�j-�-k.J`-�, SN:QR�t�{2'Yrc�
Date Tested for Accuracy:�'��p
Remarks:
The above is certified to be true at the time of testing.
FumNamel��o�..n„�laa.c,1L F�e, ��-►eh Firm Addresst�Q 9�'�- U►1s�ir+Qe-1.� �, �6$
Certified Tester(print)�1�..��rb�- Certified Tester(signature)
Firm Phone#2!'�.Y�Itf,31R'�1 Cert_Tester No.BPO�lL9yS Date 1!/}�1(r�
*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