2017_0712 IRRIGATION V DOMESTIC FIRELINE
The following form must be compteted for each assembly tested. A sigmed and dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: C1TY OF COPPELL PWS l.D. #057Q040
(Customer)
MAILING ADDRESS:
CONTACT PERSON/PHONE: —
LOCATION OF SERVICE: '7�-1
The backflow prevention assembly detailed below has been tested and maintained as reyuired by
commissian regulations and is certitied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle Reduced Pressure Principle-Detector
�Double Check Valve Daubie Check-Detector
PressureVacuumBreaker 5pill-Resistant Pressure Vacuum Breaker
Manufacturer Yv►�wY�$ Model Number �C✓Q Size 3 -7
Located At �0�(1'l' Yard Serial Number Re�,.�b�p
Is the assembly instal(ed in aecordance with manufacturer recommendations and/or local codes?__��________
Reduced Pressure Princi le Assembf Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air[nlet Check Valve
I st Check 2nd Check
field atZ,.��psid t�eld at f .Z- psid Opened at Opened at Held at
Initial Test Closed Tight.� Closed Tight � psid psid psid
Leaked Leaked Did not open Did not open C.eaked
Repairs!
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at___ Held at
Repair t:losed Tight ' Closed Tight psid psid psid
Test gauge used:Make/Mode(�'n�0�� �0'�� �Sv SN: O�LCJ��
Date Tested for Accuracy: ��—�—� �
Remarks:
The above is certitied to be true at the time of testing.
FirmName ��QW[� ��Q(�Firm Address ��� b ,
.
Certified Tesker(print) (Ya��4. �'r� Certified Tester(signature)__ _
Firm Phone# `'f�J!��"a��1_ Cert.Tester No���Z.0�2 Date �J �Z�.�
*TCST REt'URUS MUS"I'BE KEPT F�UR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Capy Pink-Tester's Copy