2017_0628 1RRIGATtON DOM ESTIC F I R E LI N E
The follo���in� form must be completzd for each assembly tested. A signed and dated originat
must be submitted to the public u=ater supplier far recordkeeping purposes:
BACKFLO��'PREVENTION ASSEMBLI'TEST AND MAINTENANCE REPORT
NAME OF P4�'S: CITY OF COPPELL PK'S I.D. #0570040
(Ct�tom�er)
MAILII�G ADDRESS:
COI��'TACT PERSON'PHONE• �e �C
LOCATION OF SER��ICE: �� �{6D��5�..��
11�backtlau•prevention assembl}�detailed below has been tested and maintained as required by
commission regulations and is certified to be operating�4�ithin acceptable parameters.
TYPE OF ASSEMBLY
-Re�6ced Pressure Principle Reduced Pressure Principle-17etector
cj�oubleCheckValve Double Check-Detector
PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker
Manufacturer W� ���.�5 Model Number � Size `/''
L+acated At �tit&,..� �c.� � Serial Number lq653��
Is the as�mbl}�installed in accordance ti��ith manufacturer recommendations and/or local codes?�__
Reduced Pressure Pnnci le Assembtv Pressure Vacuum Breaker
Double Check Val�•e Assemblv
Relief Valve Air]nlet Check Valve
1 st Check 2nd Check
Hetd at a-'1 psi Held at�'1 psi Opened at Opened at Held at
lnitial Te$t Closed Tight Closed Tight ps►d psid psid
Leal:ed Leaked id not open Did not open Leaked
Repairs
Materials
L°sed
Held at psid Held at psid
Test After Op�ned at Opened at H�ld at
Repair C�osedTight ClosedTight psid psid psid
Test gauge used: Makeltvlodel o _ SN: 1 Z13Z5{S
Date Tested for Accuracy: ��.7 r-!
Remarks:
The above is certified to be true at the time of testing.
firm Name (�.��st� Firm Address l'��b-bk �.1755 � /����
,
�
Certified Tester(prim) •r Certified Tester(signature)
Firm Phone#_�-���� Cert.Tester No. t Z _Date ,�� ?.�' '/1
'TEST RECORDS IviUST BE KEPT FOR AT LEAST TNREE YEARS
'*llSE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy
+� _