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2016_0223 . � 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) � �� #� ��, �x ,7�p0� MAILING ADDRESS: 6� I'�` CONTACT PERSON/PHONE: �� LOCATION OF SERVICE: D i* 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 1Re d Pressure Principle 7Reduced Pressure Principle-Detectar ouble Check Valve ❑Double Check-Detector f]PressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker Manufacturer Model Number (�b 7 Size � �� Located At ��/K�r�t�(C��5�' Serial Number 3!�a 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 o�'�psid .Opened at Opened at Held at Initial Test Closed Tight _ Closed Tight I— psid psid psid Leakedf ! Leaked❑ Did not open L.J Did not open I_1 LeakedC I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight� ClosedTight Cl psid psid psid Testgaugeused:Make/Model �� /Il�r$ SN: ��(��7'J� Date Tested for Accuracy: lQ aa �j� Remarks: The above is certified to be true at the time of testing. Firm Name�FLl �i��'��U Firm Address �( �� I ��/T" Certified Tester(print�� "Il6y-�' Certified Tester(signature � / p,! � �� Firm Phone# ac ��r�� Cert.Tester No.d��N� 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) �/ // MAILING ADDRESS: ��SS4'��`6 � CONTACT PERSON/PHONE: LOCATION OF SERVICE: B � 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 AS5EMBLY �Reduced Pressure Principle -JRe -ed Pressure Principle-Detector ClDoubleCheckValve i ouble Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker `/[k�`CJ L�7`�%�l�' Size�_ Manufacturer Model Number Located At �fc�1�4JT��l�0��11�t�L/� Serial Number Il�1�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? (1�-' 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 Tight�� Closed Tight �� psid psid psid Leakedn Leakedn Did not open ❑ Did not open !� Leaked� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight C� Closed Tight f'�� psid psid psid Test gauge used:Make/Model d �►'l�s SN: ��b�'tc7 � Date Tested for Accuracy: � o� Remarks: The above is certified to be true at the time of testing. FirmName��Q��l� Firm Address�`l� � �t��lEl� �<JC 7�� Certified Tester(print) � Certified Tester(signature) Firm Phone# �� `G�a� Cert.Tester No.�l�� Date 4 �'� �� * 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