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2016_0114 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 recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COP ELL PWS LD. #0570040 (Customer) �,1rQ .•J MAILING ADDRESS: 3LQ�0 I�Y�LLG �'I'�l.l.l�l� �U11� 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 ��R duced Pressure Principle ❑Reduced Pressure Principle-Detector ouble Check Valve C�Double Check-Detector ❑PressureVacuumBreaker f,Spill-Resistant Pressure Vacuum Breaker Manufacturer VVQ�S Model Number 10� .� Size �� Located At (��,� S •S�,(�,P_ 0� �I_Q�VI Serial Number /vo IG�c,/ 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 lst Check 2nd Check Held at psid Held at psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight � psid psid psid LeakedCl Leaked�I Did not open ❑ Did not open ❑ Leakedl��l Repairs/ �� V �� S�... { �Sir � Va-�v('..S � ��^c-(�'l.`� �(.� u C.�' Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight_�I psid psid psid Test gauge used: Make/Model i �� 1 SN:D�O"Z�� Date Tested for Accuracy: I o�'3" / Remarks: The above is certified to be true at the time of testing. FirmName �'��" �1f� � Vo�.e��Ft`L¢Srh1��irm Address P�• gax �tis�(B ��''�,i� �a15`�� Certified Tester(pr:n '�i� Certified Tester(signature) Firm rhonc� Q� �7-333 .�5� � Ccrt.TcstcrNo. ��'�1�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 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) ��p1� Z MAILING ADDRESS: �[g�.g �Q L�t'-{�I�t.1lY CONTACT PERSON/PHONE: LOCATION OF SERVICE: �UU►'I�SL� 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 �R�uced Pressure Principle ❑Reduced Pressure Principle-Detector l�iDouble Check Valve '7Double Check-Detector �1PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer w(�'S Model Number��M� Size �� Located At 1/ s• D� Serial Number a T Is the assembly installed in accordance wi manufacturer recommendations and/or local codes? QS Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air lnlet Check Valve 1 st Check 2nd Check Held at�.� psi Held at�psi Opened at Opened at Held at Initial Test Closed Tigl�t� Closed Tight � psid psid psid LeakedCJ LeakedCl Did not open LI Did not open 'i J Leakedl�l Repairs/ Materials � Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight 1-1 psid psid psid Test gauge used: Make/Model I1L�� •t�n� �"� SN:V��J�� Date Tested for Accuracy: �a'3' /-5 Remarks: The above is certified to be true at the time of testing. FirmName �"� �lC �' �ow��l'►��s'h�rm Addressl'-0• Qo� �5��$ -��'(n�e�-.N„�I�C,'�IDl7�j Certified Tester(print �iin� Certified Tester(signature) Firm Phone# $��"a 3�'SS�7 7 Cert.Tester No,�Po�l� � �� 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