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2015_1211 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: CONTACT PERSON/PHONE: LOCATION OF SERVICE: � ' i•t/ � � 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 -1Reduced Pressure Principle �Reduced Pressure Principle-Detector �uble Check Valve -]Double Check-Detector :JPressureVacuumBreaker !Spill-Resistant Pressure Vacuum Breaker Manufacturer �� Model NumberU�/y1� Size � Located At iV u/, �,��T��"e_, Serial Number /S�o7q Is the assembly installed in accardance with manufacturer recommendations and/or local codes? �� Reduced Pressure Princi ]e Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �� psid Held at �1 �psid Opened at Opened at Held at Initia]Test Closed Tigh1G+'1'� Closed Tight l� psid psid psid Leaked'i 1 Leaked� Did not open I Did not open I I Leakedi I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight L I Closed Tight��-_I psid psid psid Test gauge used: Make/Model �,�/� T�S► Sr SN: p �v�je�� Date Tested for Accuracy: /�•-/o - 1 SJ Remarks: The above is certified to be true at the time of testing. Firm Name t(Cxc�,.,�� i�'+�S Firm Address Pa �{a��! 7-�f� LJ�,I � 7S1�� Certified Tester(print)��j'�, (:vvi�4.c,� Certified Tester(signature) ,��;...�� /�_ Firm Phone# ��'�Z�- '�-�-F�`7 Cert.Tester No. $P Oa� fo/S'7 Date /Z -// /� * 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 LD. # 0570040 (Customer) MAILING ADDRESS: � 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 C�Reduced Pressure Principle 7Reduced Pressure Principle-Detector a.P'�ouble Check Valve I Double Check-Detector L iPressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker n Manufacturer F�/g P� Model Number �p Size�� Located At ,{� /��7 t�C'`"�� Serial Numbe�7�� .S'�a� '��"�� 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 C.�psid Opened at Opened at Held at Initial Test Closed TightF� Closed Tight � psid psid psid Leaked� I Leaked'� I Did not open ; ; Did not open f I Leakedl 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight LJ ClosedTight�- psid psid psid Test gauge used: Make/Model -�ti,,�.!"L�u,M 'T� $' SN: d 7 4 9'�-t�� Date Tested for Accuracy: �i-/D- 1 S-' Remarks: The above is certified to be true at the time of testing. FirmName�c.�.�, �--�� yds Firm Address �t� /��-rC Jc! �dl�G /l� '�S'/ 6� Certified Tester(print)�j,��Certified Tester(signature) . Firm Phone# ��-'�� Cert.Tester No. C�P o� ��s 7 Date l L - /1- I 5� * 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