RPZ_2015_1216 R G" �
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)
MaiLIN�aDD�ss: j 31 � 5 . ��_ 1 � .1-�- �.,,,�_ � �l i
CONTACT PERSON/PHONE: �l ( /�
LOCATION OF SERVICE: ; •t,9,r � v a (�i v' i I �3 I � 5 , �)N �'+�''�
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
Cv'Reduced Pressure Principle I�Reduced Pressure Principle-Detector
❑Double Check Valve �`��Double Check-Detector
❑PressureVacuumBreaker C:�Spill-Resistant Pressure Vacuum Breaker
�- 1 �1 � �
Manufacturer � Model Number V� � r'�,�`c 1 Size O'
1 �<< S. Rel+�
Located At � « � � Serial Numberrl j � S ��1 l�
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 Cbeck 2nd Check
Held at�"� psid Held at�`� psid Opened at�-� Opened at �Held at
Initial Test Closed Tightivl� Closed Tight � psid psid psid
Leakedl�I Leakedf i Did not open � Did not open � 1 Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
y� r �
Test gauge used: Make/Model o '�- (iV�� b `�� SN: %U� � 1�/ � �
Date Tested for Accuracy: � " ��� � �
Remarks:
The above is certified to be true at the time of testing. �
Firm Name ���('1'y►��� �= r'� �K A ddress 1 U��� ���'► C �� �� `�� »✓
Certified Tester(pri nt) �C/���� I�G�er�ed Tester(signature) �_ ��!
Firm Phone#� 1� � `� 1�1�i ( Cert.Tester No. GU 1 S�I (J Date /�—�b�� �
* 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