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 recardkeeping purposes: �
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS 1.D. # 0570040
(Customer)
MAILING ADDRESS: �O 3 ��' ` ��I ��
CONTACTPERSON/PHONE: L.e�1�5 0.Cfa-S ZI`f '4 � -f30�
LOCATION OF SERVICE: ��(�( C l)�^rzv�o,�e,� C��r
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
I�educed Pressure Principle C�Reduced Pressure Principle-Detector
i�DoubleCheckValve I��Double Check-Detector
� ��1PressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker �
,- 1q J +� ��
Manufacturer W��S Model Number �Q / /1� Z Size � �Z
Located At U. �t� I� Serial Number �-I ���Z ���
, --r
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 at psid Opened at� Opened at Held at
Initial Test Closed Tightl Closed Tight I� psid psid psid
Leaked f�I Leaked'�1 Did not open '� I Did not open I I Leaked I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight L�'�� Closed Tight. I psid psid psid
Test gauge used: Make/Model �rvi DI'a CD '�0- Zoo ?IL SN: ZSrQd b0
Date Tested for Accuracy: q/�8���$
Remarks:
The above is certified to be true at the time of testing.
FirmName l�bd�('�� -L-SU Firm Address � � I,V Y
� � Certified Tester s� nature
Certified Tester(print) Q �� ( �g )
Firm Phone# ���7��p- �J�f� Cert.Tester No. �d������ Date � �� ��
* 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 �