2016_0427_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:
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: 7.�� U r+�T'j,y�',U G/y
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 IReduced Pressure Principle-Detector
���-'Double Check Valve i Double Check-Detector
'� ��PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker
Manufacturer Lv/�, /�/S Model Number �.Sd Size�
Located At_��iv� �/�¢/iQ Serial Number/�.�5� 74�
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 ataf '�psid Opened at Opened at Held at
Initial Test Closed Tigh� Closed Tight� psid psid psid
Leakedl I Leaked. I Did not open I I Did not open I '� 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� psid psid psid
Test gauge used: Make/ModelCl��n �t4-r,??5�L � u SN:OIIXJ�-/[� 9 �
Date Tested for Accuracy: �'1 !/` )` �
Remarks:
The above is certified to be true at the time of testing.
FirmName 5� � � Firm Address1�,�„��ASIIJif'y�..� �/'�Y��C ��
Certified Tester(print)YI2��l�jfyL,�(�/L �Certified Tester(signature���������C�%l�
Firm Phone��a7—��(j�3 �3 y Cert.Tester No. O .5�� Date �1
* 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