2017_0317_RPZ IRRIGATION DOMESTIC FIRELINE �1 ��,�,?-
li �The following form must be completed for each assembly tested. A signed and dated original ,��3 (,
must be submitted to the public water supplier for recordkeeping purposes: �� •1J� (� 3-6
�1�\-► � V
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) � �� ���� � � � �,A .
MAILING ADDRESS: f�
CONTACT PERSON/PHONE:
LOCATION OF SERVICE: O '� 'f�
The backflow prevention assembly detailed below has been tested and maintaine as required by
commission regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
�+Reduced Pressure Principle -Reduced Pressure Principle-Detector
� ��Double Check Valve �Double Check-Detectar
----- -- -P-�essurcVacuumBreaker Spill-Resistant Pressure Vac�u� Breaker
���_ ���� 1 Size '�'��)
Manufacturer Model Number
3 Go�M�bt{��}r`^2�1'��lh� Serial Number l d' (��O�
Located At (�Y1t��.f �
Is the assembly installed in accordance with inanufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembl Pressure Vacuwn Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
I st Check 2nd Check
��S� Held at� sid Held at�•� psid Opened at� •� Opened at Held at
Iilirial Test Closed Tight , Closed Tight� psid psid psid
Leaked 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� I���'�S �(7l J SN: ����� 7 O /
Date Tested for Accuracy: 6
Remarks:
The above is certified to be true at the time of testing.
Firm Name�f-t���� � Firm Address � � 6 S ��� �• �•`�'�� �-� � er�x
Certified Tester(pi-�nr) P,r ��f�'S�Certified Tester(signature
Firm Phone# U��'� 7 / "� �� � Cert. Tester No�Pd � � �i 9� Date �— 7
* 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