RPZ_2016_0122 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 LD. # 0570040
(Customer) ��� �X � ��l�
MAILING ADDRESS: 3 p�' �
CONTACT PERSON/PHONE: 't.. ;� ' Z i �{ (a- b t.�p
LOCATION OF SERVICE: �
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
��educed Pressure Principle !�Reduced Pressure Principle-Detector
�DoubleCheckValve -7Double Check-Detectar
����IPressureVacuumBreaker i-Spil1-Resistant Pressure Vacuum Breaker
l � ��
Manufacturer �Q�( S Model Number D�q � 7i Size � �Z
Located At Q 1 I r � Serial Number �J 3�� �
Is the assembly installed in accordance th manufacturer recommendations and/or local codes? e�
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air lnlet Check Valve
1 st Check 2nd Check
Held at 7�� psid Held at psid Opened at 3�� Opened at Held at
Initial Test Closed Tight�i Closed Tight '� I psid psid psid
Leaked�1 Leaked�I Did not open I 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'�J Closed Tight�.7 psid psid psid
Test gauge used: Make/Model��ry� �rILC� ��" Z�O-��CSN: �s g�d U
Date Tested for Accuracy: g ������'�
Remarks:
The above is certified to be true at the time of tesring.
FirmName �f -�—s � Firm Address ��W el'� Y:
yQ � � �
Certified Tester(prsnt) �t� I�t � Certified Tester(signature) �
�/ �[� f��
Firm Phone# �l �! `T�o r�O 7 U Cert. Tester Na OQ�'p7� 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