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2015_0923 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) MAILING ADDRESS: �30� ��h I�"�r � e�� U� 7 D(� CONTACT PERSON/PHONE: Lo�� I'1�c>c-�aS Z� ` 9�0•-$!��{U LOCATION OF SERVICE: Z�� koR [�t0 A m1 n�5 C� io� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is cerrified to be operating within acceptable parameters. TYPE OF ASSEMBLY [Reduced Pressure Principle "-iReduced Pressure Principle-Detector [�oubleCheckValve -�'��Double Check-Detector ❑PressureVacuumBreaker 7Spill-Resistant Pressure Vacuum Breaker �' r► Manufacturer �e C� Model Number �� Size � Located At Nor-�h, S F*o�t2 D f I�t'nP,�rk�Serial Number � � t��o 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 at �'� psid Held at 2� �psid 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 Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at � Repair ClosedTight❑ ClosedTight[i psid psid psid Test gauge used: Make/Model �r�M��c.o ��`Z�n �� SN: Z S S o �� Date Tested for Accuracy: Q I �8 ,S Remarks: The above is certified to be true at the time of testing. Firm Name C��I .�-S� . Firm Address �� hJl�i1C�' �1�� 'el I � ('''�� r . Certified Tester(print) e•C�V�d�� '�'1 � Certified Tester(signature) Firm Phone# 2�� —��'5�� Cert.Tester No.P`�� 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 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) I MAILING ADDRESS: �3�� W�°"� `e� �r � el� � ~� p� CONTACT PERSON/PHONE: o�:i s Yncic�u5 �-��I ' �f�i� g 0�� LocaTioN oF sExvicE: zoo S, �opei 1 Koad �� s o� ��e,Mer�� 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 ��duced Pressure Principle ��Reduced Pressure Principle-Detector oubleCheckValve I�IDouble Check-Detector C_��Pressure Vacuum Breaker f�Spill-Resistant Pressure Vacuum Breaker r� Manufacturer ��L� Model Number �S� Size Z Located At �n� D� � �'ia�' Serial Number �0�s�� 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 at ��Z psid Held at �'`� psid Opened at Opened at Held at Initial Test Closed Tight�d Closed Tight 'F� psid psid psid Leaked. 1 Leaked'.1 Did not open I Did not open I . Leaked I Repairs/ Materials� Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I- Closed Tight I 1 psid psid psid Test gauge used: Make/Model��`'1��0.C-� �� SN: ��d Date Tested for Accuracy: ��/� �� Remarks: The above is certified to be true at the time of testing. Cf, � »o� ��n ��- �r Firm Name D1�6�( � �� Firm A ddress �' �� , � Certified Tester(prsnt)�CtV�� 1 Certified Tester(signature) Firm Phone# Z�-T '�_I��g�7d Cert.Tester No.��7� Date � zj �s * 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