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2015_1124 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: �Oal �055 �Vc ��cZ�F�� OI C�NTACT PERSON/PHONE: I� LOCATION OF SERVICE: �I^1_�_ o+/�J,Tiwl�. 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 ::il�educed Pressure Principle `1Reduced Pressure Principle-Detector �'�oubleCheckValve : IDouble Check-Detectar ��PressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker � Manufacturer �'�� Model Number U��/� � Size� Located At��T� bw �firce�, 3 Y�AI f•0�' �I��' Serial Number 5a 3�3 Is the assembly installed in accordance with manufacturer recommendations andlor local codes? �� '�'S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held�•� psid Held a��psid Opened at Opened at Held at Initial Test Closed Tigl1� Closed Tight� psid psid psid Leakedf I Leaked` I Did not open I� Did not open I I Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight L'� ClosedTight f I psid psid psid .✓ ,/ Test gauge used: Make/Model � b � ' � SN: �� v�7�dZ. Date Tested for Accuracy: L y ��' �`� Remarks: 1r.[. i l�ti w�/l�sS The above is certified to be true at the time of testing. Firm Name �OG�C✓ f I�+G �G T6CTl4�/ Firm Address�� D�yi`/�`L� ��.T�� 2� Certified Tester(print)� � �" Certified Tester(signature) __ �- Firm Phone#�ly'3.'��ef�3593 Cert.TesterNo.��00/�0�� Date � � G r� * 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) �✓G/+/K t� �f MAILING ADDRESS: o'2O i oS5 VC. �a�:�fl -r • '� �r CONTACT PERSON/PHONE: I i �I�h G '� • S 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 ' Reduced Pressure Principle �iR�r duced Pressure Principle-Detector �=DoubleCheckValve �P'Double Check-Detector -'PressureVacuumBreaker � Spi11-Resistant Pressure Vacuum Breaker Manufacturer i/�� Model Number �� L�� Size�_ Located At ,IJ ��{,.,��. ��/ �<� J��01�� O��Seria�Number�Db�fi / �OD�- Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? 3 Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held�psid Held a�•� psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight� psid psid psid Leakedl ''� Leakedl 1 Did not open I 1 Did not open f�' Leaked�'� �� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight LJ Closed Tight ��I psid psid psid Test gauge used: Make/Model ��/0 I l��1'u SN: ��D��Z• Date Tested for Accuracy: �`�_/� �� Remarks: Tbe above is certified to be true at the time of testing. Firm Name I�OG��I(�� f 1��'�� Firm Address ��V a �� Certified Tester(print) �/�l�'1� �1`GYCG Certified Tester(signature) Firm Phone��"��3�� Cert.Tester No.� �a �� Date �'"��'ly * 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