RPZ_2016_0613 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: ��j O l�r 2X' C�r � �I �LGLS
CONTACT PERSON/PHONE: L�u�5 rnc�.C.io� zl - �f � — D U
LOCATION OF SERVICE: I ZD a-�c�^�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 �1Reduced Pressure Principle-Detector
f 7DoubleCheckValve C]Double Check-Detector
CPressureVacuumBreaker f-'Spill-Resistant Pressure Vacuum Breaker
11 c i�
Manufacturer �,t}O��ts Model Number LF�� I �3 Q—f Size ��_
Located At ����� ��eld Co,(1CCSSfOY1 Serial Number �z�s(�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��eS
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 $•� psid Held at � psid Opened at Z�Z Opened at Held at
Initial Test Closed TightlX Closed Tight C'� psid psid psid
Leaked�I Leaked❑ Did not open �.�� Did not open [�l Leakedl I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight[�I Closed Tight�-1 psid psid psid
Test gauge used: Make/Model��� � �D-- zCx3�� SN: ZS S fSDC�
Date Tested for Accuracy: 9�/$f�l�
Remarks:
The above is certified to be true at the time of testing.
FirmName��DAL�2�� ��� Firm Address �O�J � �
�
Certified Tester(print) � �� ( Certified Tester(signature)
Firtn Phone# �� —���o' p�� Cert.Tester No. W 'S Date � �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