2016_1219 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 recordl<eeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: ' ' t'�
CONTACT PERSON/PHONE: uiS ' S � 'jf G ��SU
LOCATION OF SERVICE:
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
�iR duced Pressure Principle '-!Red�iced Pressure Principle-Detector
ouble Check Valve Double Check-Detector
! 1PressureVacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker
� t��7/�/ � Size �j�
Manufacturer WQ Model Number
Located At �I��G/°���I Serial Number � 2r� 7T
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?�e;s
� Reduced Pressure Princi le Assembl Pressure Vacuwn Breaker
Double Check Valve AssemUly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
Held at ��3 psid Held at Z�� psid Opened at Opened at Held at
I 1 Test Closed Tighti i Closed Tight I 1 psid psid psid
��j�j Leakedl I Leakedl � Did not open I Did not open ! Leaked '�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Re�air Closed Tight' I Closed Tight'' I psid psid psid
Test gauge used: Make/Model �n'1 f�1�L..D �`a�d�L- SN: ����d�
Date Tested for Accuracy: �' /�P �/�
Remarks:
The above is certified to be true at the time of testing.
FirmName���� �-�� Firm Address ���� �ei`� Cel►''• � i �
� Certitied Tester(print) (�U iC�\���'� Certified Tester(signature) � t
Finn Phone# ���``C�� �oo`r� Cert.Tester No. �1 ����� Date Ia2 I / I
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REFLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy