RPZ_2016_0120 IRRIGATION DOMESTIC v 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 1.D. #0570040
(Customer)
MAILING ADDRESS: ' C�-, �I� '�C ��p�
CONTACT PERSON/PHONE: i `Q ' Z i �f�lG,-- G
LOCATION OF SERVICE: ZGO 5� (�ert}�n f��p,
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
��Reduced Pressure Principle �Reduced Pressure Principle-Detector
C��DoubleCheckValve �'�Double Check-Detector
��1PressureVacuumBreaker �: ISpill-ResistantPressure Vacuum Breaker
Manufacturer t��s Model Number �(`�1 .�-�� z�
�'1� I �'` Size
Located At �� � e Serial Number ��j� ���
Is the assembly installed in accordanc 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
Q0�`� Held at �'� psid Held at �� � psid Opened at Opened at Held at
Initial Test Closed Tight��C' Closed Tight � psid psid psid
Leakedl l Leakedl 1 Did not open 1 Did not open i Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight J Closed Tight�I psid psid psid
Test gauge used: Make/Model Com br�co `'t'���a���L SN: Z�gdQd
Date Tested for Accuracy: q_��l/5
Remarks:
The above is certified to be true at the time of testing.
Firm Name C� ,1 IJ Firm Address I�JD��` 1�7t �� , � 2�1 1 �j���'
Certified Tester(pr�nt) U����A 1� Certified Tester(signature) �
Firm Phone#��7' ���o��O�� Cert.Tester Na DP���� Date ���` ��
* 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