Prologis Park-LR160610IRRIGATION DOMESTIC FIRELINE
The following farm must be completed for each assembly tested. A signed and dated original
most 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. N 0570040
(Customer)
MAILING ADDRESS: _ Z5'ol 1j i4at tj,.e.j
CONTACT PERSONIPHONE: cI'7
LOCATION OF SERVICE: •••
The backflow prevention assembly detailed below has been tested and maintained is required by
commission regulations and is certified to be operating wnhin acceptable parameters.
TYPE OF ASSEMBLY
Reduced Pressure Principle Reduced Pressure Principle -Detector
Double Check Valve ruble Check -Detector
PressureVacuum Breaker Spill -Resistant Pressure Vacuum Breaker
Manufacturer L). i 6d e%j Model Number 3 S0 A STV&Size
OJj1;0e4fP•a^F
Located At c Serial Number C7 l
Is the assembly installed in accordance with manufacturer recommendations and'or local code, `
Test gauge used: MakelModel SN: 0/1/&9S
Date Tested for Accuracy: 6 —to —Ib
Remarks:
The above is certified to be true at the lime of testing.
Firm Name ADVGLI LU&4� 62 C,6�irm Address d otaK 3 .27 7XK@4Ky(]jg, V 793$
Certified Tester (print) i X 9& Ceruried Tester (signature).- �!1
Firm Phone r~ 691440147]q 401- Cert. Tester No P --Date
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE WARS
"' L15E ONLY MANUFACTURER'S REPLACEMENT PARTS
White- City Copy Yellow- Customer Copy Pink- Tester's Copy
Reduced Pressure Prince )e A. mbiv
Pressure Vacuum Breaker
Double Check Valve As%embly
Relief Valve
.fir Inlet
('heck d'altc
I st�Cyhe;ckkt
end Check
Held aY►-0 p}at�
Lj
F{cld at psi
Opened at
O➢acncd at
13r1d at
Initial Test
Closed Tightly
Closed Tight
paid
psid
psid
Leaked
Leaked
Did not open
Did not open
Leaked
Repairs
Materials
Used
Test After
Held ac— psid
Held at psid
Opened at
Opened at
field at
Repair
Closed Tight
CloscdTight
psid
psid
psid
Test gauge used: MakelModel SN: 0/1/&9S
Date Tested for Accuracy: 6 —to —Ib
Remarks:
The above is certified to be true at the lime of testing.
Firm Name ADVGLI LU&4� 62 C,6�irm Address d otaK 3 .27 7XK@4Ky(]jg, V 793$
Certified Tester (print) i X 9& Ceruried Tester (signature).- �!1
Firm Phone r~ 691440147]q 401- Cert. Tester No P --Date
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE WARS
"' L15E ONLY MANUFACTURER'S REPLACEMENT PARTS
White- City Copy Yellow- Customer Copy Pink- Tester's Copy