RPZ_2016_0913 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)
MAILING ADDRESS: (3�3 � r 2. �
CONTACT PERSON/PHONE: I-e��� ia 2t 4 - '�`t(. -�o�o
LOCATION OF SERVICE: a �S '�
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
1�Reduced Pressure Principle �Reduced Pressure Principle-Detectar
❑DoubleCheckValve �7Double Check-Detector
[ 'PressureVacuumBreaker :ISpill-Resistant Pressure Vacuum Breaker
� tL, 3ir
Manufacturer lN0.`�t'C� Model Number L. � �t Size
Located At�O(1'(�`�S�bn �e� rbor� Serial Number �OZ�03 E7315
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 Ci•� psid Held at psid Opened at 2�Z Opened at Held at
Initial Test Closed Tighti�l Closed Tight ❑ psid psid psid
Leakedl ' Leakedl.l Did not open 1 Did not open I Leakedl '
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight I 1 ClosedTight_ I psid psid psid
Test gauge used: Make/Model ��m�c_O ^Cf�- 2��IL SN: ��0C7d
Date Tested for Accuracy: q�1� � �S�
Remarks:
The above is certified to be true at the time of testing.
Firm Name e��Q�l 1 SL Firm Address 1303 Cc�nanc I E'i/ �v.
�
Certified Tester(print) i���� Certified Tester(signature) C
Firm Phone# ��`f— `T�l(o`���v Cert.Tester No. d SS Date l 3
* 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