Prologis Park-LR160610 (2)IRRIGATION DOMESTIC 1 --le,
rIRELINE
The following form must be completed for each assembly tested. A signed and elated original
must be submitted to the public %nater xupplier for reeordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITE' OF COPPELL PWS I.D. # 0570040
(Customer)
MAILING ADDRES,
CONTACT PERSON
LOCATION OF SER
The backflow prevention assembly detailed below lras been tested and maintained as required by
commission regulations and is certified to be operating within acceptable parantcters,
TYPE OF ASSEMBLY
Reduced Pressure Principle Re ced Pressure Principle -Detector
Double Check Valveouble Check -Detector
Pressure Vacuum Breaker Spill -Resistant Pressure: Vacuum Breaker
Manufacturer LJ, r..5 -ModelHurn r 9;; 0X4- Size 3/y
Tr
Located ANA!slt` Gt+-� rte- Sena[ Nurnbe- 2- $
Is the assembly installed to accordance w nth manufacturer recommendations and'or local ccxies' �
Test gauge used: Make/Model WM; TP_1r1gr_ SN:_(�l
Date Vested for Accuracy; 6 —+ a ' e <m
Remarks:— _
The above is certified to he true at the time of testing.
Firm Name MV* dE{( P ia,'<G ! Firm Address�P015r �[ e J c -7 r1�c1 i 4+'✓r ]-(7 j 3i
n
Certified Tester (print) KI AIeIAvtd r' CertiliedTester (signature r.{� — - --e!✓
Firm Phone # Ceti. Taster No.._G P5,15 Le Date I—//-/->
«TEST RECORD'S MUST BE KEPT FOR AT LEAST THREE YEARS
.s USE ONLY MANUFACTCIR'EWS REPLACEMENT PARTS
White- City Copy ifelio'W- Customer Copy Pink- Testcr's [ cep}
Reduced Pressure Pnncirplc A., cinbly
Pressure Vacuum Breaker
Double; Cheek Vah a Assernhl
Rcliet, % alee
:err Inlet
Check l;'ahe
1stCheck
2nd Check
Held at{• 3' psid
Held at r - - psid
Opened at
Opened at ..
Held at
Initial Test
Closed Tight /_
Closed Tight
psid
psid
psid
Leaked
Leaked
Did not open
Did not open
Leaked
Repaim
Materials
Used
Test Ager
Held at psid
field aE psid
Opened at
Opened at
I trid at . f
Repair
Closed Tight
Closed Tight
psid
psid
psid
Test gauge used: Make/Model WM; TP_1r1gr_ SN:_(�l
Date Vested for Accuracy; 6 —+ a ' e <m
Remarks:— _
The above is certified to he true at the time of testing.
Firm Name MV* dE{( P ia,'<G ! Firm Address�P015r �[ e J c -7 r1�c1 i 4+'✓r ]-(7 j 3i
n
Certified Tester (print) KI AIeIAvtd r' CertiliedTester (signature r.{� — - --e!✓
Firm Phone # Ceti. Taster No.._G P5,15 Le Date I—//-/->
«TEST RECORD'S MUST BE KEPT FOR AT LEAST THREE YEARS
.s USE ONLY MANUFACTCIR'EWS REPLACEMENT PARTS
White- City Copy ifelio'W- Customer Copy Pink- Testcr's [ cep}