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 ASSEMSLY TEST Al�TD MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) .
MAILING ADDRESS: '�'6'
CONTACT PERSON/PHONE•_�,,�,�,���ly q3o � �
LOCATION OF SERVICE: �f,I L�be�h-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 �Reduced Pressure Principle-Detector
�(DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer Qt«1e� Model Number�t�]t.h� _ Size l�
Located At Serial Number�� �3�l� �
Is the assembly install 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�.�p Held at�psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight C� 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 ClosedTight❑ ClosedTightn psid psid psid
Test gauge used:MakelModel�� �j-2p�-�kJr�, SN:�j ly2Yf�'}
Date Tested for Accuracy:�'%y/!(..
Remazks:
The above is certified to be true at the rime of testing.
Fum Name��o�•.o�bn� ��t ��+rs��► Firm Address i�� ��-.t/��L+acl.��_T7� �b�
Certified Tester(print)�1,..`'T�w�r- Certified Tester(signature)
Firm Phone#21'�.�{�►i1.3tR'�I Cert.Tester No.�POdlL9�IS Date f���f tc
*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