2016_0314_RPZ IRRIGATION DOMESTIC C 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: N. N .�' I� • 7S�I�
CONTACT PERSON/PHONE: � �F �'2 " / — O
LOCATION OF SERVICE: N. N � I �
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 'JReduced Pressure Principle-Detector
I'�DoubleCheckValve -7Double Check-Detector
C PressureVacuumBreaker � ISpill-Resistant Pressure Vacuum Breaker
Manufacturer (�l�� Model Number �Q� Size l ��
Located At �01�,% i'�(,o� �� Serial Number �3 ���0
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
P�75 Held at��psid Held at 0' psid Opened at �� Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
3_ ��� Leaked �l Leaked'�1 Did not open �� Did not open C I Leaked'��1
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I��� ClosedTight f I psid psid psid
. �
Test gauge used: Make/Model ����/Ns ��S— SN: �Od�0.��7
Date Tested for Accuracy: 2�/���•
Remarks:
The above is certified to be true at the time of testing.
FirmName/� /KUff �J�f�-�"��''� Firm Address 2d � /�C� !x•
' 7s/2�v
Certified Tester(print)�Cff�7Q� ��C.Certified Tester(signature)
Firm Phone# ������� ���� Cert.Tester No. ,81'��(�37� Date 3�� — 6
* 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