2017_0427_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: n �/D� rc'�SS� �"�e�S I bv �O<ti�1�5 /X� �-5���'f
CONTACT PERSON/PHONE: - � -� ��
LOCATION OF SERVICE: C� Cr• SS 1nJ�L � !�s .
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
'6�Reduced Pressure Principle ❑Reduced Pressure Principle-Detectar
❑DoubleCheckValve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
�/
Manufacturer�u,� Model Number 9,�� Size��
Located At t-►i`e ���SC�-i" ('�t�M Serial Number 0� �f���(�
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? a�
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�psid Held at �'�ps� Opened at o`l• I 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
;';
Test gauge used: Make/Mode1�8��4 �/�-'�(? �'7��5'i,� SN:(�'}//%//�/�
Date Tested forAccuracy: �"�I'��
Remarks: I�o i��
The above is certified to be true at the time of testing.
FirmName ��$ �'�/`e C�i�ti�,.�hiC:• Firm Address�(oD� ��r�'�-� �/���
Certified Tester(print)Il�'�.�Pc� �a/�'1FZ Certified Tester(signature) -
Firm Phone#�1�--�`��/�—�I(?�? Cert.Tester No.�j�(�1�3��-j�% Date `�'"'027"'� /
* 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