RPZ_2016_1219 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 recordlceeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS l.D. # 0570040
(Customer)
MAILING ADDRESS: .�d3 (�r�cirl 'L✓ �� �� ���
CONTACT PERSON/PHONE: ou�5 Q �a
LOCATI ON OF SERV ICE: //:3 a✓►�!.c� S /L�
The backflow prevention asse►nbly detailed below has been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
educed Pressure Principle '1Red�iced Pressure Principle-Detector
�,fDouble Chec a ve 'Double Check-Detector
! IPressurcVacuumBreaker -',Spill-Resistant Pressure Vacuum Breaker
j � j� q�q � � Size ��
Manufacturer W1�77s Model Number
Located At �U S�d��ci r C I�5�� Serial Number ��� � 7�
Is the�ssembly installed in accordance with manufacturer recommendations and/or local codes? �s
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
� Double Check Valve Assembly
Relief Valve Air lnlet Check Valve
i st Check 2nd Check
Held at �! psid Held at psid Opened at .3�� Opened at Held at
�' ial Test Closed Tightl i Closed Tight I 1 psid psid ps��
��j Leakedl I Leakedl ; Did not open ! Did not open ' Leaked' I
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair ClosedTight' I ClosedTight� I psid psid psid
Test gauge used: Make/Model �/►7 �Prz[-D �d " 2o D '�,�SN. 2�gOC1U
Date Tested for Accuracy: ��l� I��o
Remarks:
The above is certified to be true at the time of testing.
Fir�n Name ���P��' is� Firm Address � ��� � '�' �\� � e�I
� (p � )�C�Ut� \�c'�i�� CertifiedTester(signature) t'w"' `
Certified Tester rant
Firm Phone# ��?�`���"���`�� Cert.Tester No. �����°7�� Date � �9 l
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REFLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy