2016_0314_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: D S. A�G B � G� �ELL �I�
CONTACT PERSON/PHONE: <S t,u �/Z 2 — 2-
LOCATION OF SERVICE: g• M (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 �Reduced Pressure Principle-Detectar
! IDoubleCheckValve -]Double Check-Detector
' IPressureVacuumBreaker �Spi11-Resistant Pressure Vacuum Breaker
Manufacturer (,�A'� Model Number (� l(}�.T Size ��2 y
Located At �'IjDI/€ I'�'w � sl�� Serial Number z 32.3�T
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 �i•7 psid Held at �'7 psid Opened at� Opened at Held at
imtial Test Closed Tighi'�1 Closed Tight�, psid psid psid
3_��—��p Leaked' I Leakedl I Didnotopen '��� I Didnotopen I�I Leakedl-'��
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C1 Closed Tight C�� psid psid psid
Test gauge used: Make/Model � ���1 N S � l. — S SN. �t70 p0�8�
Date Tested for Accuracy: 02—�-/�
Remarks:
The above is certified to be true at the time of testing.
Firm Name �i /KvS-�' ��IG/Ow Firm Address Z 0�� �� � �� �
Certified Tester(pr�nt) ��G�}a� �� Certified Tester(signatu e �X' ��u
Firm Phone# �� � ������.21� Cert.Tester Na 03r Date J'����o
* 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