RPZ_2015_1112 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) ^ �, /'
MAILING ADDRESS: ���3 W h� ��r �--i� l.v �f � ��
CONTACT PERSON/PHONE: �Prc.�lS Ct(.t'ec5 �r � �f 9 —S6 C�
LOCATION OF SERVICE: 3/3 p��c� S V
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 �1Reduced Pressure Principle-Detector
�ouble Check Valve ❑Double Check-Detectar
�1PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
�- t i
Manufacturer �"'e �.0 Model Number � S U Size 2
Located At �'r��1� D� SG�dO� Serial Number (� ���ZZ
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
1 st Check 2nd Check
Held at 2�� psid Held at 2�0 psid Opened at Opened at Held at
Initial Test Closed Tight�lC Closed Tight;`!� psid psid psid
Leakedf 1 LeakedC; Did not open f I Did not open ' I Leakedl ���
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair GosedTight❑ ClosedTight I I psid sid
p psid
Test gauge used:Make/Model lAM►J r t�.LO ��'Z�� SN: Z�g D�C�
Date Tested for Accuracy: � ��l ���
Remarks:
The above is certified to be true at the time of testing.
Firm Name ���'l I � �lJ Firm Address �J� W�L?11 �I�' � .lI�
v
Certified Tester(print) I �� Certified Tester(signature)
Firm Phone# �I I —T /�P ��� Cert.Tester No. �I �1��p75� Date � � �Ij' r
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Ye11ow-Customer Copy Pink-Tester's Copy �,