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2016_0115 IRRIGATION DOMESTIC FIRELINE V �.,� 5 "� 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) �� (�2�'�t�—r ^ � MAILING ADDRESS: �� OV� l �(�L CONTACT PERSON/PHONE: LOCATION OF SERVICE: �, YY�R� 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 �� R�ced Pressure Principle-Detector ��ouble Check Valve �'Double Check-Detector '�PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �(]_�S Model Number -'1� y-�C �D� Size�_ ,n �;1v�h� S�no�' Located At ��j,U�d��n,��QQ,��Q,�,�I`Q. Ser�al Number �� 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 aZ �� psi Held at 3• a' psid Opened at Opened at Held at Initial Test Closed TightC Closed Tigh psid psid psid Leakedn Leaked❑ Did not open � Did not open L 1 Leaked��i Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTightLJ ClosedTight'��J psid psid psid Test gauge used: Make/Model��l�ln S � � SN: ��p c�7'�� Date Tested for Accuracy: ��3'� �7� Remarks: The above is certified to be true at the time of testing. FirmName�'� h<C d' p6�s�'� ��"irm Address �� • P°X' 7�� r��'�"'��( ?g Certified Tester(pr:nt) � � Certified Tester(signature) Firm Phone# 4�17 "�� •�S 1 ? Cert.Tester No. �j�0��>3�'� Date (� o ��..---� * 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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. #0570040 (Customer) `_�jPil/��i '� MAILING ADDRESS: � �l r r CONTACT PERSON/PHONE: LOCATION OF SERVICE: r1nA� 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 JReduced Pressure Principle ❑Reduced Pressure Principle-Detector �Double Check Valve ❑Double Check-Detector -1PressureVacuumBreaker C�Spill-Resistant Pressure Vacuum Breaker Manufacturer��(�S Model Number �0� 1�'�01- Q:� Size 3I� Located At �U ��1'� V�� j S�G Na��Serial Number �. � (p(Q� �/' Is the assembl— y�alled in accordance with manufacturer recommendations and/or local codes? T es 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 a•a psid pened at Opened at Held at Initial Test Closed Tight:' � Closed Tight L psid psid psid Leaked�] Leaked' 1 Did not open ��-� Did not open ❑ Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight��] Closed Tight C: psid psid psid g g � ��r c �'� SN: D�t � 7�J 7 W Test au e used: 1Vlake/Model � Date Tested for Accuracy: �a�� Remarks: The above is certified to be true at the time of testing. FirmName�vrl �1't�i d' WWtp��n�Firm Address �a. B°)�' 7�8 �/�"�L�►�f'�1'�(' 7(� 7`� Certified Tester(pr:nt) �✓1 Certified Tester(signature) Firm Phone# ��7 �3� '�� 7 Cert.Tester No. b rOa I S�8� Date l� I 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