2017_0224_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)
MAILING ADDRESS:
CONTACT PERSON/PHONE: -
LOCATION OF SERVICE:�,j�:1r����' ,�'�- ^`-4�i 6,`�� �=;j� �v � � ���,� ; .�� ::.�i � ��,����='ti��'r:
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
��IDoubleCheckValve Double Check-Detector
' PressureVacuumBreaker -!Spill-Resistant Pressure Vacuum Breaker
� ��Manufacturer �Jl� �t,`�'�s- Model Number vC�� Size
\ Located At � �h O�� �� Serial Number ;�.�.� 1 � �
�,•��Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
O Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
) J2�
� Double Check Valve Assembly
( �� Relief Valve Air Inlet Check Valve
,y� n 1 st Check 2nd Check
y �'�
�� Held at psid Held at 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
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight ' Closed Tight psid psid psid
� 's� � �� r '� �
Test gauge used: Make/Model���J ���"��f� � SN: � 1���x �
Date Tested for Accuracy: ��^ �-�- " f ��
Remarks:
The above is certified to be true at the time of testing.
Firm Name\�� f f�4 11+ ���%i f..�#`���-�� r`.��l;'�'1�`; Firm A ddress 1`�i'I�' i �t:�' �il�;�' '��:�"��'���� fl F�
. 4�`-,j i..�:�ti1-� 'i'•�A'�-J�_;
Certified Tester(print) � i.t�( � ' �r �' . Certified Tester(signature)
Firm Phone# � J::`f .`l j� � ✓'��_- Cert.Tester No:_.�t�y�,�'�i=-1�L Date ,� � lf���
* 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