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2016_0114 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 recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPP LL PWS I.D. #0570040 (Customerj � �'L�� 3 MAILING ADDRESS: I � � PG�ILI�ULI,(,I 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 ❑Reduced Pressure Principle I 1Reduced Pressure Principle-Detector C Double Check Valve C�uble Check-Detector CPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �(� Model Number �� Size �� rt� �1' Located At �� 1� �� Serial Number (�✓�lCau�a��e 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 a p Held at� sid Opened at Opened at Held at Initial Test Closed Tigh� Closed Tight psid psid psid Leaked❑ C'� Leaked��-I �'�Did not open C� Did not open � Leakedl�I Repairs/ y�- / L r Materials �l�t' ( 7 �� 5��..�' '0 1'F �9� ��.t �L 11� �/��ctC,l�(�l � Used Held at psid Held at psid Test After Opened at Opened at Neld at Repair ClosedTight� ClosedTight C� psid psid psid Test gauge used: Make/Model�� '�) �� SN: (' (o�7a�1 �o Date Tested for Accuracy: � �' "�'�5 Remarks: w Vv�!X��,(i,c,� I � The above is certified to be true at the time of testing. FirmName �''� .,/'� ��h��s�h��irm Address�_� •� ?s�'�a �p.�- G�'�,%k7�/'7j Certified Tester(print) J�-o Certified Tester(signatureY i Firm Phone# iv��"�3� 'S�7 � Cert.Tester No.� Pao1S�u � 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 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) � 3 MAILING ADDRESS: � I3� � I�GYt�iJQ.�/ 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 �Double Check-Detector ��PressureVacuumBreaker '� 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer��s Model Number �6�� Size 3 � Located At IV� VQ�,I.Q� �p,l �'X.I,Ir�U,YIG (,4f- Serial Number��(,n,rOatJca�,�C. Is the assembly installed in accordance with manufacturer recommendations andlor local codes? QS 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 o�'�' psid Held at�.`-�psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight - psid psid psid Leakedl I Leaked' 1 Did not open ❑ Did not open -1 Leaked' 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight�I psid psid psid Test gauge used:Make/Model �/U�r ��rs �'� � SN' d��?� S7 �p Date Tested for Accuracy: �a� � '/ `� � Remarks: �„ The above is certified to be true at the time of testing. � � FirmName �--� 'i�� d' ��-h'��Eirm Address {�� (�ox 7y;y9 �r w�� k 7c�i�7 Certified Tester(prin 'h N� Certified Tester(signature) Firm Phone# u �?"�3 a '�S 7 "�] Cert.Tester No. � ��3�'� Date /(v * 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