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: ��
CONTACT PERSON/PHONE•�n,;�,��1y �t3o �A �
LOCATION OF SERVICE: 7 5E� L�1oe�t-�
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 Q.►.�1� Model Number�_fn�X�$ Size ("
Located At Serial Number 1� �� C7'��
Is the assembly installe in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuwn Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at J-� d Held at 3�0 psid Opened at Opened at Held at
Initial Test Closed Tight� Closed Tight B� psid psid psid
Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑
Repairs/
Materials
Used
Test After Held at psid Held at psid Opened at Opened at Held at
Repair Closed Tight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Modelg�� HO-2�'b-�'J`—�, SN:Q�t�{ZYfc�
Date Tested for Accuracy: Sf�l�p
Remarks:
The above is certified to be true at the rime of testing.
FirmName,��o�.,Q,,,,��nc� F�� ���, Firm Addresst�0 � ��`� . 4�ac1.r.� �' �b"b
Certified Tester(print)�1� � Certified Tester(signature)
Firm Phone#2]�1,N�IiI.31q'•1 Cert.Tester No.3POOlZ9`IS Date 1���/I(o
*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