2016_0511_RPZ 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: I( � 7 S � � �L�L�I�'�
CONTACT PERSON/PHONE:_5'TGfl�i1-` SGGF��y119/2� � �l �G�3 �� ��S
LOCATION OF SERVICE: I/'' �/�T�T� �'I L-��'�/? �C%��0�"l � ,-r,�„�i5'��
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
I��educed Pressure Principle � 1 Reduced Pressure Principle-Detector
I�=iDoubleCheckValve � IDouble Check-Detector
I�IPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
� „
Manufacturer I.�°��(_�j Model Number ������ Size
Located At j%�LZ-'/�r�� 1�{t"ff( �✓L J��i��'I Serial Number�5 ���;J 3 �
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
Inirial Test Closed Tightl Closed Tight f psid psid psid
G=�a����0� Leaked� Leaked��=-l�� Did not open f � Did not open � I Leaked� I
Repairs/
Used ials �G' l �� ,,, _ /J��� � �
�� ✓
Held at�psid Held at >� psid �j � O ened at Held at
Test After Opened at r p
Repair Closed Tight� Closed Tight� psid psid psid
Test gauge used: Make/Model �1�� '-i/���5� SN: �J����1
Date Tested for Accuracy: �5�-��� L y-}5%
Remarks:
The above is certified to be true at the time of tesring.
Firm Name t� � �12�"� �, ���C'SC�`1% Firm Address � � �"1 .�i ����11��G�
�� � �
Certified Tester(print) f�C��°✓ ����a!�C/�'✓ Certified Tester(signature) .�i,,(%2 1�'.��G�"�"`-
Firm Phone# ��� ���v �-��� Cert.Tester No. �,����;%�C' ��� Date � ��l���
* 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