RPZ_2015_1123 ( �
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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer) � ���� �� �.���
MAILING ADDRESS: �� 3� ��� ��� � .I
CONTACT PERSON/PHONE:r`�-k u
LOCATION OF SERVICE: 2 7 U I �"'- I -�-�►�-
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
/C'�.Reduced Pressure Principle �: Reduced Pressure Principle-Detector
C��DoubleCheckValve ❑Double Check-Detector
'JPressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker
//
Manufacturer W Model Number ��7 Size �
Located At N�w� Cvr�u' ��..�G,(t��`S� Serial Number��o G 6
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? `e5
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 a�:'� psid Opened at � � Opened at Held at
Initial Test Closed Tightl ��� Closed Tight : 1 psid psid psid
� Leak �1 Leaked�Q Did not open ��1 Did not open f�� Leaked��� �
Repairs/ ����w� � �b�S �
Materials �� �4� ���
Used
Held at - psid Held at C• psid
Test Afte y Opened at�'2 Opened at Held at
Repai � Closed Tight� Closed Tigh� psid psid psid
Test gauge used: Make/Model W i ll�>>'`S � � � SN: Q 6 0�QS(�
Date Tested for Accuracy: S���� 5
Remarks:
The above is certified to be true at the time of testing.
Firm Name ��� �"e�� Firm A ddress �2�C S r��"� �,1, f�t,��(.� �lC 76 Z��
Certified Tester(print)��`�10.."�l H G'�(���Certified Tester(signature)�,M'� �^
Firm Phone# ��7`�������� Cert.Tester No.��Q��Z�� Date ��`7i��
* 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