2017_0307_RPZ IRRIGATION DOMESTIC �C 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) p� �j
MAILING ADDRESS: 0 O �'`�4c. �ifli �.�o Cv ' Tsi. 7sQ/q
CONTACT PERSON/PHONE• � 2 — Tn G - /y G,��-/9/�
LOCATION OF SERVICE: O S 7Hvr2 L✓� # �ofl
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
�(iReduced Pressure Principle -1Reduced Pressure Principle-Detectar
� IDoubleCheckValve � '��Double Check-Detector
� IPressureVacu��33Breaker iSpill-Resistant Pressure Vacuum Breaker
,�. / �//
Manufacturer G�g� Model Number �9�T Size
Located At �D✓& �,0 JI�/� Serial Number .?3� 3��'
—�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��
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�l7 Held at�psid Held at 7/ psid Opened at� Opened at Held at
Initial Test Closed Tight�, Closed Tight'�j psid psid psid
ps 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� i psid psid psid
Test gauge used: Make/Model �/D- �✓E5� ��� SN: �D�///7
Date Tested for Accuracy: .2—�—� 7
Remarks:
The above is certified to be true at the time of testing.
Firm Name �/ �i (JSf,BA�Uf.��OGJ Firm A ddress ZD Ca¢G I?,C, Gf�D
• ?X• ?S?.�-�o
Certified Tester(pr�nt) /G /S� Certified Tester(signatur
Firm Phone# .�/� 3�S' 7oZ�0 Cert.Tester No. Date �7�/7
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy