RPZ_2015_1110 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) r ��
MAILING ADDRESS: � � �� w�aY� �eY ��✓
CONTACT PERSON/PHONE: i$ (�,�'US Z14—4�C.,--��i4cU '
LOCATiON OF SERVICE: I lo I ��o,f?re
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 ,JReduced Pressure Principle-Detector
�9Double Check Valve I�����Double Check-Detector
'JPressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker
Manufacturer �Gl� Mode1 Number ��� /� I � Q ! Size�
Located At � � ���e Serial Number �i 0 ��
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 Opened at Held at
Initial Test Closed Tighti7l° Closed Tight �' psid psid psid
Leaked��1. Leaked.��I Did not open . ] Did not open f� Leaked'� I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight� ' Closed Tight�� I psid psid psid
Test gauge used: Make/Model 1'h1��C��O �f�` Z�0 �, 2��d(�Q
Date Tested for Accuracy: � �� ��J
Remarks:
The above is certified to be true at the time of testing.
n ��+ � ` . ��`
Firm Name lA��� .�J� Firm Address �7j W YL� l�-
� A �
Certified Tester(prxnt) � Certified Tester(signature)
Firm Phone# ���" — �q(r—B�� Cert.Tester No. ��� 7 Date f� ��/�'S
* 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