RPZ_2015_1027 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: � 3 03 l�rct►� 1�;,� ��,�. � 1 � �)C
CONTACT PERSON/PHONE: �-o u i b �cic i a 5 �� `� - 5�o-- O `F U
LOCATION OF SERVICE: I�-U ak�� ��
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certified to be operaring within acceptable parameters.
TYPE OF ASSEMBLY
� educed Pressure Principle I��Reduced Pressure Principle-Detector
�ouble Check Valve �� IDouble Check-Detector
-1PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �G2.-�-�-5 ModelNumber L-� ����1 Size 3,,
Located At Fva��J u.�� �o n C:C55 i �n �11C� Serial Number �4 Z�b3 �3�rj
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve � Air lnlet Check Valve
1 st Check 2nd Check
Held at �a�� sid Held at p id Opened at Z�� Opened at Held at
lnirial Test Closed Ti ht Closed Ti ht psid psid psid
g g
Leaked ! Leaked 1 D�d not open ' Did not open f 1 Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at �
Repair Closed Tight f Closed Tight I_! psid psid psid
Test gauge used: Make/Model Co m br�Lv y(�- ZOd\�L SN: Z`�g'nt�0
Date Tested for Accuracy: �'1 ( Z5 I 1 S�
Remarks:
The above is certified to be true at the time of testing.
Firm Namel�PP��1 �5 p Firm Address i�� ��r`o��1 ei� ��r �I �
Certified Tester(print) � � Ct t �'� Certified Tester(signature) � � �
Firm Phone# Z�� "�{.�la ���Q Cert.Tester No.�P[��(��]S�Date �C� �7 I�
* 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
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 LD. # 0570040
(Customer) /�
MAILING ADDRESS: � 3 �3 l.� i�-►1�1P�' l��r , �.p PpQ� � �X
CONTACT PERSON/PHONE: i� 1'In�ra`�t Zl�{— SlGJ'� ��D�b
LOCATION OF SERVICE: � ZO IJo�-��, �•-, j�a�
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
�educed Pressure Principle ��Reduced Pressure Principle-Detector
[J Double Check Valve �!�Double Check-Detector
�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer VJQ��-5 Model Number �--���-3 �� Size 3��}'�
Located At �E�a-t��r ���C'.1a �ceS�lOf� Serial Number �Z��
Is the assembly installed 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 ��psid Held at psid Opened at 2� (� Opened at Held at
Initial Test Closed Tight'� Closed Tight ! I psid psid psid
Leakedf 1 Leakedf' Did not open I J Did not open '� I Leakedl��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight I ��� Closed Tight I_' psid psid psid
Test gauge used: Make/Model �►^n brACO ��'Z��K SN: Z5$�Ch�
Date Tested for Accuracy: � �Z`�' I 1 S�
Remarks:
The above is certified to be true at the time of testing.
Firm Name�-O p(a��1 J— ,S,o . Firm Address ���3 W �{` �p � (�
Certified Tester(print) 1 le� Certified Tester(signature)_����
Firm Phone# Z�'t ����a�b Cert.Tester No. I�I d�O�J�U Date r2� j�
* 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