RPZ_2017_0120 IRRIGATION DOMESTIC ✓ FIRELINE
The following form must be completed for each assembly tested. A signed and dated ariginal
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)
MAILINGADDRESS: ��"� r=c�.e.�o�-E ��wti , Lv;��� , � 3sD�
CONTACT PERSON/PHONE: G v� {foa w �- 02 - lv ' 3� �2
LOCATION OF SERVICE:�� F�e��� Pku:�/
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�educed Pressure Principle �Reduced Pressure Principle-Detector
❑DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker i�Spill-Resistant Pressure Vacuum Breaker
Manufacturer ��'�'�'S Model Number �0�1 � � Size a �i
Located At h �a�✓-e b�X �� v� r��'��'�. Serial Number ���� S
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? C-5
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 Tighb�� Closed Tight C3� psid psid psid
P4 j Leaked❑ Leakedill Did not open �] Did not open '�I Leaked'�
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight❑ ClosedTight❑ psid psid psid
Test gauge used:Make/Model ���b�'r�ca �G � aac�- TKS SN: Gt o�a�(��,
Date Tested for Accuracy: t� r� 3 � l fv
Remarks:
The above is certified to be true at the time of testing.
` n T s-f�w�
FirmName .Dp� �✓P,�(� t��..y l�uC,�'��w Firm Address t`1�� f�b`�C�c� Ct ,��l�c. ,� �'�5�
Certified Tester(print)�i^�:�,� �rx�c(f" Certified Tester(signature) ...1�:-���,---/
Firm Phone# � �� - �� �- �o`(L S Cert.Tester No. ��C�d��c?�7Z S Date f �C' ��
* 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