2017_0217_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 recardkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040
(Customer)
MAILING ADDRESS: ,,�D� Sv�1� OCn�Y` `�'ap (L�� Ga��� Tl� � +7SOl°1
CONTACT PERSON/PHONE: I�CG�;�H V�v��� b�Z—LL� — D-�s 7
LOCATION OF SERVICE:��c�l S t'7r,vi+o� ��o
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.
� L TYPE OF ASSEMBLY
�'Keduced Pressure Principle i7Reduced Pressure Principle-Detector
❑DoubleCheckValve �7Double Check-Detector
�Pressure Vacuum Breaker "�l Spill-Resistant Pressure Vacuum Breaker
��
Manufacturer W� �$ Model Number L F�'J��YY1 ZQ�[' Size 2
Located At R 1 SL r �OQ�1 Serial Number �5 2-�d 6
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? , C
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 1d•�{psid Held at�psid Opened at �"�� � Opened at Held at
Initial Test Closed Tight�Y Closed Tight ►� psid psid psid
��Sf Leakedf; Leaked�� Did not open L1 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'J psid psid psid
Test gauge used:Make/Model C p Y��DYG�G O y 0�2,Ob T kS srr: U 10 2 Z Z 6 G
Date Tested for Accuracy: � Z3 �((,
Remarks:
The above is certified to be true at the time of testing.
�h�
Firm Name .• �0�1 (VL x�' c�u� ��� Firm Address (L'� �1 pl b�t�nL C-�
Certified Tester(print) �S�A C� �r��r�Certified Tester(signature���.����
Firm Phone# 214 " ���' 6�� s Cert.Tester No. $P(�U �6 G� 5 Date Z �� � �'
* 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