RPZ_2016_1230 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: 7 7 �0�� �'1����^-��wl��t�`���'G�II 7�� �SUC g
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: �� ? S'u�k4c c.ac' �r la`�r2P '�J o I al
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
�duced Pressure Principle - Reduced Pressure Principle-Detector
��Double Check Valve -�Double Check-Detector
1PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer '�"��S Model Number QU� �� Size
a,,
Located At L!1 �4�c�1C c�k ia�r�e�✓'1�/ydi✓' ,�'�'C✓ Serial Number 0 �O�' qa�
Is the assembly installed in accardance with manufacturer recommendations and/or local codes? - 1
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 a�`� psid Held at j0•�. psid Opened at �,� Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
(b�;S Leaked� I Leaked Did not open Did not open 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�����+�y''�L"'�� SN: G/�Sa 5��
Date Tested for Accuracy: �`S� �
Remarks:
The above is certified to be true at the time of testing.
FirmName Q���SSQ���7��-e���'U'L�irm Address ���3Na/lc>������i".�`�7`� 76U��
Certified Tester(pr�nr)��-� ,�.rdh� Certified Tester(signature) ,.i2%�d�C7
Firm Phone#��,5 �� ��a � Cert.Tester No. ��yQ 7� 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