2017_0215_RPZ 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) I
MAILING ADDRESS: L' �"'� '
CONTACT PERSON/PHONE: � s-i(��— �S� �"'JS��
LOCATION OF SERVICE: �_ r ;y.r� a�
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
IiDoubleCheckValve CDouble Check-Detector
❑PressureVacuumBreaker C�Spill-Resistant Pressure Vacuum Breaker
, ` n ►�
Manufacturer W Model Number ��(�/�,���'��� Size ��-^
—��,�
Located At �v,n,5 �c�w. Serial Number ��-1'�—�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? r-"
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�p d Held at�ps� Opened at��S Opened at Held at
Initial Test Closed TighT„� Closed Tight � psid psid psid
Leakedl 1 Leaked��� Did not open ��7 Did not open ��� Leaked❑
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight C Closed Tight� psid psid psid
Test gauge used:Make/Model! 1 tC��'�f�S�S s��� sN: L l� 6 i`� l �
Date Tested for Accuracy: ��/����(p
Remarks:
The above is certified to be true at the time of testing.
FirmName���� `�6�.6������F'C�"'�i� Firm Address PU �USC ��7, P{�r'L��'Or I�� /"/
Certified Tester(print) ���C:� Certified Tester(signature) � ��
Firm Phone# �1�-I)d��-���3 Cert.TesterNo�fGi���S33 Date L�-'�— ��
*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