RPZ_2016_1229 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) ' ZWv
MAILING ADDRESS: ���� � ' �e•��'1 r� 1�'�/`�- �,`aS �1�,��,
CONTACT PERSON/PHONE: G�c''e� m�Y�l� 1- ��j '7 '�U -3 3��''1 l S�'�- ��o
LOCATION OF SERVICE: /'� f � S �Q �-�' �•%A C��Y'Q- I
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
C'I'T�educed Pressure Principle f"1Reduced Pressure Principle-Detector
❑Double Check Valve C'�Double Check-Detector
❑PressureVacuumBreaker f�Spill-Resistant Pressure Vacuum Breaker
Manufacturer �u�� Model Number �G� ��„�`Cr Size
� ��
Located At j�`��c- �� Serial Number U� � S 7 �
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 U•� psid Held a�•G psid Opened at �•� Opened at Held at
Initial Test Closed Tight�t7� Closed Tight � psid psid psid
Leaked❑ Leaked�� Did not open C Did not open ❑ Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight;�J Closed Tight � psid psid psid
Test gauge used:Make/Model �-�r,v�S� �� �— SN: �U� ��G��
Date Tested for Accuracy: S" ��- '� b
Remarks:
The above is certified to be true at the time of testing.
Firm Nam�1� �h"�''��4. �'��e� Firm A ddress �U���l. G�'`'� �'���� `✓a��k I �
Certified Tester(print) I ►�u��,� ���-�^ur� Certified Tester(signature) �- �
Firm Phone# ��'� Ci.C����5 � Cert.Tester No.��UU!���U 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