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2015_0825 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 LD. # 0570040 (Customer) MAILING ADDRESS: , CONTACT PERSON/PHONE: — 7 � - a 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 oubleCheckValve CDouble Check-Detector '��pressureVacuumBreaker �rSpill-Resistant Pressure Vacuum Breaker Manufacturer �F{"�'�rj Model Number L��d� Size � 1� Located At 1 1�1 N V / �•Wa �i�Yl('_1/ Serial Number aa�3�3 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held atr�� ps' Held at �� ps' �Opened at Opened at Held at Initial Test Closed Tightl�� Closed Tight !� psid psid psid Leaked 1 Leaked�� I Did not open I I Did not open I Leaked��I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at HEId at Repair Closed Tight'�_l Closed Tight[.�� psid psid psid Test gauge used: Mak�/Model w► i ki 1'1S / I C_TL� SN: � �d��Q�� Date Tested for Accuracy: r�'�� Remarks: The above is certified to be true at the time of testing. Firm Name 1 ' �'��(�1)�'!'�[_Firm Address��(_�'�� .Pt1�"��1 !��T�_�q Certified Tester(print) �E � Certified Tester(signature) � Firm Phone#c��`�`��'�� Cert.Tester No.�)(j�a�7�}`t' Date� a�� * 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 IRRIGATION v 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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. #0570040 (Customer) MAILING ADDRESS: e CONTACT PERSON/PHONE: — 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 I_� duced Pressure Principle ��Reduced Pressure Principle-Detector I� ouble Check Valve C Double Check-Detector I PressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker ( �r Manufacturer F�F IVlodel Number �� Size Located At M��/ I �,(�t�w �Y I'l�✓ Serial Number �� g�QO"� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve l st Check 2nd Check Held at�Qp � Held at�•a psi Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight � �� psid psid psid Leakedf ' Leaked'.l Did not open I Did not open ' ' Leaked i Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight'�� I ClosedTight I psid psid psid Test gauge used: Make/Model W i � �i Yl� / I C�� SN: (�� (��r]q Date Tested for Accuracy: �—�b� �� Remarks: The above is certified to be true at the time of testing. Firm Name�`��1Pl�i�Kt(L"�Ll��,r^C, Firm Address �'.�,�C1�� l�C,C)y SV i �f�.T�(�� - r - , � _ Certified Tester(pr:nt Certified Tester(signature) Firm Phone# �,��Q��—��Cert.Tester No�QQ�� 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