2017_0531_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) r.1 ,�� � ,���/�
MAILING ADDRESS: J� 3 3O Cc
CONTACT PERSON/PHO : ` s � / '3 Q� ��
LOCATION OF SERVICE:
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
�educed Pressure Principle �Reduced Pressure Principle-Detector
❑DoubleCheckValve ;�Double Check-Detector
❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker
Manufacturer �,, n � Model Number %/�/� � d�, Size
a ''
Located At�Q,UI.Q1�'U�4-�JV.JL6a?)'1/ Serial Number � I J � / �1 '
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? /J/
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�+ 0 psid Held at�a 0 psid Opened at��� Opened at Held at
Initial Test Closed Tight� Closed Tight � psid psid psid
Leaked❑ Leaked' i 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 ��r� �:ZQ�� O �J`^�'J� SN: C�(P� �� �J' ��
Date Tested for Accuracy: / ' ��"��
Remarks:
The above is certified to be true at the time of testing.
(� ► y) �.�. �l h �_�n o
Firm Name��� 1.�.�.�1.�� Firm Address�o���� �s I�I�U!L�/�CNL.J���?�X�/,Ld.��.5v���7
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Certified Tester(print) ��81"�0.C�by�'-Certified Tester(signature) �
Firm Phone#/f o('"0�"0 '�7dQ Cert.Tester No�PQO����� Date �"���� !
*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