2017_0605_RPZ IRRIGATIOi�! DOMESTIC v 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 ASSEi�IBLY TEST Ai�TD i1�AINTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040
(Customer) rot
MAILING ADDRESS: � l � Ste rr� �� ��'�-lJ C �'35 i�+��afr�5 �j%-�G� /�v ���?lf�X`�.5�19
CONTACT PERSON/PHONE: r a'��y� �1 'b'�l�
LOCATION OF SERVICE: � �eSS :�r: �� -
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 ASSEIV�Y
❑Reduced Pressure Principle educed Pressure Principle-Detector
❑Double Check Valve ❑Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer IN► ���r S Model Number ,�7� Size �,/
Located At ►?^e_ �'��5�� /`Fc1H'►. SerialNumber $�j�3��
Is the assembly installed in accardance with manufacturer recommendations and/or local codes? �'v��
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�p id Held at �> � ps d Opened at a�+ Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
S s Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑
Repairs%
Materiais
Used
Held at psid Held at psid
Test After Opened at Opened at Held at
� Repair ClosedTight❑ CtosedTight� psid psid psid
�
�.;
Test gauge used:Make/l�Iodel��Qc�/jb �/G'`����-7�15`' sN: a jt ir/�G
Date Tested for Accuracy: �'",j /-' �6
Remarks: �c���� •
The above is certified to be true at the time of testing.
Firm Name N��.5 r�iL�v� i Z�L� Firm A ddress o2�04� /]�cc.�a�na.-� �`�-�� (�u-��� �S�`l/
Certified Tester(print)�J L�f�'� �Dm�'Z- Certified Tester(signature)
Firm Phone rt �t y"3`������°p Cert.Tester Na�PD�7 I�i�tt`l Date_�p Nu�/'�
* TEST R�CORDS .tiIliST L'E KEPT FOR�T LE.-�ST THREE YE A�2S
**USE ONLY�it�ti`liFACTURcR'S REPLACEI�IENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy