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2015_0818 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:��ec�e Cen�4e( S1�55 �el l�r 5prirp 5 I� � 5� 3c�C� f��S�:r'e�( -']�(x,� CONTACT PERSON/PHONE: Ke S �n q~l —T��35Co LOCATION OF SERVICE:�e� l l.� S[3� V �QY-P P.CY.v� . 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 �Reduced Pressure Principle I educed Pressure Principle-Detector ��=JDouble Check Valve �ouble Check-Detector '_7PressureVacuumBreaker ��Spill-ResistantPressure Vacuum Breaker Manufacturer ��j�O Model Number �.S�Q Size � �c Located At v Au.�� IV W �'k�n�� Serial Number � Q�Q�� 1�11 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? C S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve � C�j 1 st Check 2nd Check Held at��psid Held at� ��psid Opened at Opened at Held at Inirial Test Closed Tigh� Closed Tight�' psid psid psid Leaked�] LeakedCl Did not open I.1 Did not open �i�_] Leakedl 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 C�ti \k�t�5 � �S sN: ('�3 7 �3 U 3 � Date Tested for Accuracy: �'� —I � Remarks: The above is certified to be true at the time of testing. Firm Name.�l2Ca� ��cc- d S�c�.�.r`�� Firm Address�,oq�3�n-�_ �iC' �1� - FT•�i�� I(s Certified Tester(print)i�czcr�S �{-�.�� Certified Tester(signature��/I�j,(,►� ��IC1/ Firm Phone# �\7-��-I��3 Cert.Tester No.(��(�I�((a� � 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 far each assembly tested. A signed and dated original must be submitted to the public water supplier for recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040 (Customer) MAILING ADDRESS:C PP� � e -..�� -�\ tt' r�(� S " F}c�d �Yj�� 1 CONTACT PERSON/PHONE: 1�� 11 S t�� G� �-- �- S � �S�� LOCATION OF SERVICE: e 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 f�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector �Double Check Valve '-1 Double Check-Detector ❑PressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker Manufacturer ��C d Model Number O�cj y i� Size � �� Located At �/��-�- � i,� CC�f n�( Serial Number �� 5�.9�� 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 (� �s 1 st Check 2nd Check 1 Held at�psid Held at�•�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked[1 Leaked�7 Did not open I ' Did not open Cl Leakedl � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight 1 Closed Tight f ' psid psid psid Test gauge used: Make/Model t��k�i�S T(� 5 sN: �312 3� 3 ) Date Tested for Accuracy: �� I S Remarks: The above is certified to be true at the time of testing. FirmName�r;- � �ir� a �-2c�r�}yFirmAddress�9��3 �,/��LLv�� 1� • �T•C.�=`I . I)( 1�11�' . � CertifiedTester(print)�f�C�15 �p�},-c.t�CertifiedTester(signaturel � Q� � Firm Phone#�11-��—��U� Cert.Tester No. ��d��3 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