2016_0401_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 LD. # 0570040
(Customer)
MAILiNGADDRESS: Cc�.�e, Ambrosio.,�50('_o,•,�c,r �r 5}�e lgo� Capp�,�l�7ll�?5o�q
CONTACT PERSON/PHONE: �c�.So r� 1'-1�i �I�f - 2 ZZ -55 Iq
LOCATTON OF SERVICE: ''15v Cc��ah p�-iv� .�C-e �SO
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
jl�Reduced Pressure Principle CReduced Pressure Principle-Detector
-1DoubleCheckValve CDouble Check-Detector
�Pressure VacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
3�y i z �,
Manufacturer ���� Model Number �J�d� � `Y TSize
Located At �h1►� SUr�G.�u�+��--G�'� Serial Number ���O d�
Is the assembly installed in accardance 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�a �psid Held at �'S p�sid Opened at � ' Z Opened at Held at
Initial Test Closed Tight►� Closed Tight"f I psid psid psid
Leakedl ; Leakedl-1 Did not open I Did not open C�l Leaked'���I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C Closed Tight[-1 psid psid psid
Test gauge used: Make/Model ��(,4�5�-�I�y�s-� � I SN: ��Q�d��
Date Tested for Accuracy: �`� I- ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name �V�I��'1 Firm Address � � f-���� � �s���
Certified Tester(pr:nt) ��� g ��L��- Certified Tester(signature
,I� r� 5�
Firm Phone# "��"I Z����� Cert.Tester No. �PUUI Z� 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