RPZ_2016_0121 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 LD. # 0570040
(Customer) ' \ j
MAILING ADDRESS: I 3�3 W�a I�✓ ��r', ��I `� �
CONTACT PERSON/PHONE: ewr" iC1S �.�y— 6—
LOCATION OF SERVICE: //3 UG li
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is cerrified to be operating within acceptable parameters.
_� / TYPE OF ASSEMBLY
f�Reduced Pressure Principle 7Reduced Pressure Principle-Detector
f��Double Check Valve ���lDouble Check-Detector
I���PressureVacuumBreaker ��� ��Spill-Resistant Pressure Vacuum Breaker
t- � �i
Manufacturer �QT 5 M d Number ��m Size ���-
Located At US1"o�Q�r/ l,lp f� TG Serial Number �f� /��/
Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? ��
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
Held at ��� psid Held at psid Opened at�.� Opened at Held at
Initial Test Closed Tight� I Closed Tight I I psid psid psid
Leakedf � Leaked.I 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 ClosedTightl_� ClosedTight �l psid psid psid
Test gauge used: Make/Model �M D�C�CD ����� �L SN: ZS�DUD
Date Tested for Accuracy: �_�____/$' 1�-;�
Remarks:
The above is certified to be true at the time of testing.
FirmName��e�` �'"�� Firm Address �303 Wr(',t1'� � �r.
�
Certified Tester(pr�nt) U I� �� Certified Tester(signature) �
Firm Phone# ��� TI�'�/�`� Cert.Tester No I Lt/LJ �,5 Date � � 1�
* 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