2016_0523_RPZ IRRIGATION DOMESTIC FIRELINE
The following form must be completed far 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) 1
MAILING ADDRESS: � T
CONTACT PERSON/PHONE: -
LOCATION OF SERVICE:
The backflow prevenrion assembly detailed belo has been tested and maintained as required by
commission regularions and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�Reduced Pressure Principle C�Reduced Pressure Principle-Detector
I Double Check Valve r pouble Check-Detector
�PressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker
Manufacturer Z.l�� JV Model Number �1 �X L �� Size � '(
Located At Serial Number �p ��$O��
Is the assembly installed in ccordance with manufacturer recommendations and/ar 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 3� Opened at Held at
Initial Test Closed Tightj� Closed Tight� psid psid psid
Leaked' i � Leakedf I Did not open � l Did not open ! Leakedl
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTightf 1 ClosedTight;I psid psid psid
t
Test gauge used: Make/Model IU►1 b -- t;J.7��� SN: (�31��31 �
Date Tested for Accuracy: �- 1� -�(e
Remarks:T� ���� S�t�.Q�' ,
The above is certified to be true at the time of testing.
FirmName ���,,�(���,� Firm Address , � � (/1�����,
�� f v�
Certified Tester(print)��,��������1.�Certified Tester(signatur
Firm Phone# ��� -�3� �'���� Cert.Tester No. ���0 �1 � ,�' Date ��
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS �-.:(,;� � ��D
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy