2017_030717_RPZ IRRIGATION DOMESTIC �
FIRELINE
The following farm 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: ��00 A/, ,L��j� �i�p /�,{J, ��DD Co1s�L%X 757,�9
CONTACT PERSON/PHONE:�v � T / - 3 - /z
LOCATION OF SERVICE: �N 7',q,q �-jp�
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
�Reduced Pressure Principle ,Reduced Pressure Principle-Detector
' �Double Check Valve Double Check-Detectar
- -�PressurcVacuumBreaker -'Spill-Resistant Pressure Vacuum Breaker
Manufacturer_ l�A� Model Number ��Q'(� Size �.'t u
Located At_ �a/� /�j Syj�%� Serial Number ✓3 � ��
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t'$
Reduced Pressure Princi le Assembl Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
3-?��7 Held at �/'�psid Held at� sid Opened at 3•� Opened at Held at
I 'tial Test Closed Tight� Closed Tight � psid psid psid
�'� Leaked�I 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
Test gauge used: Make/Model ''//�-G✓EST �S-,� SN:_ ����///7
Date Tested for Accuracy: .Z—9 / 7
Remarks:
The above is certified to be true at the time of testing.
FirmName ft �U� Q��-F/DGJ Firm Address,�D�y S1WGE�Qpi4Cy �.., %lE�hQ�LANp
!
{� 7k. �S/2�
Certified Tester(pr�nt)IVL�� �� Certified Tester(signature) v
Firm Phone# ��7` ��.5 7i2�(' Cert.Tester No.�_,�Date .��, l rJ
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Capy Yellow-Customer Copy Pink-Tester's Copy