2016_0307_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) ,�TCC
MAILING ADDRESS: I 333 �RgSTSi e� Q� �
CONTACT PERSON/PHONE: S��vi I� p+e►�lCbe R 7 Z �7/ �8��?3
LOCATION OF SERVICE: /333 eR�srsi d£ d,c. .
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
f�duced Pressure Principle ❑Reduced Pressure Principle-Detector
❑DoubleCheckValve :�lDouble Check-Detector
❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker
Manufacturer W'�T�s Model Number �F d�`� Size 3 ��
Located At �� d U'C.K /AJ tA.k/o� R�SFI� e�cs�"� t�6 0��
Serial Number
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Y�s
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��� psid Opened at ��a Opened at Held at
Initial Test Closed Tight-B' Closed Tight �' psid psid psid
Leaked` ] Leaked'_J Did not open J Did not open n Leaked J
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
Repair Closed Tight❑ Closed Tight❑ ps�d psid psid
Test gauge used:Make/Model �'���NS �'6��S SN: C�So 7i6 D(a
Date Tested for Accuracy: � �/6 —(�,
Remarks: 02C6�NkL k'y2 �2�^��„Ij j,�qrlS Q� ��'
��F 3C�lp
The above is certified to be true at the time of testing.
FirmName UN/T�.4 /►?�c.�,�-�v��,�-i_ Firm Address llS�fb Pl.�o �t/, ,O�Lu.t�, TX 7Sz�f3
Certified Tester(print) �T" C��o�/ Certified Tester(signature) �� �- �
Firm Phone# Z�� ���� ��3cio Cert.TesterNo.��O�ll b SS��
Date � ,7".��
* 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