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2015_0817 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 '` �G .e 4 . r,. ' -, �:�) ��p�( �S(�;� CONTACT PERSON/PH E: � g'1 - ;,3 LOCATION OF SERVICE: c�, � a � 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 iReduced Pressure Principle ❑Reduced Pressure Principle-Detector '�DoubleCheckValve _7Double Check-Detector '�PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker Manufacturer �-��e n Model Number �C�s y � Size � r t Located At ��( {at�.i�- .� E C(�t�ef Serial Number N 1 � Is the assembly installed in accardance 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 psid Opened at Opened at Held at Initial Test Closed Tightf �� Closed Tight ��; 1 psid psid psid Leakedf�1 Leakedn Did not open ''�,� Did not open .�1 Leakedl�1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight�l Closed Tight�__I psid psid psid Test gauge used: Make/Model (�;�. \�t f�S 'i�5� SN: �' 31��,3� Date Tested for Accuracy: y-lr-1� Remarks: c�,nG�r�� -�e��- NU +..0 C��e r �r� �,�. ,� G�nr,�, •k4- � �i�� 'C K � �t�� -�� Caec�� C�SSe�miol+l The above is certified to be true at the time of testing. FirmName�,2G� �`�re_ � St't:�r� �Firm Address�� ix�,t �1LL� • ��"(:. t,;,'�,��( �Cti(!(�� Certified Tester(pr�nt�t'vi 5��,-'trc i 1 Certified Tester(signature��/�,t,�� ._ Firm Phone# U�1-��r3-i a�C'�_� Cert.Tester No.��(o��3 Date�--I 1-1 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 IRRIGATION DOMESTIC FIRELINE � The following form must be completed for each assembly tested. A signed and dated ariginal 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: � e ° 5 � C ef S , �,5m�'�C `�SCI�� CONTACTPERSON/PH E: 2 1a- � �3j LOCATION OF SERVICE: G �' , 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 C1Reduced Pressure Principle �Reduced Pressure Principle-Detector ��DoubleCheckValve ��uble Check-Detector -1PressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker Manufacturer p �CC? Model Number C'�j S LSj Size � Located At UGtc�.A� J E ��e�� Serial Number j��I� 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 [' � 1 st Check 2nd Check °r Held at psid Held at psid Opened at Opened at Held at Initial Test ClosedTightl I Closed Tight C1 psid psid psid Leaked. I Leaked.I Did not open L� Did not open CJ Leakedl Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight�� Closed Tight I�I psid psid psid Test gauge used:Make/Model�� 1�i�S ( �`� SN: Q 31�3Q 3� Date Tested for Accuracy: �{—�—I S Remarks: ta(1G;61�. -� �r�--�' i�i: W C� � -t� � �TL S� �'C�r I� The above is certified to be true at the tim of testing. Firm Nam� � neG� �r C� a �C��r��/ Firm Address��13 �n,p ��Q (�a`�,+ �T��-V) �j}( 1�� Certified Tester(print�V 1S t'�-l-r�1 l Certified Tester(signatur�� Firm Phone#��—��Cert.Tester No.(.��b�� 3 Date D '��'�S * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy