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2016_0115 IRRIGATION DOMESTIC FIRELINE V 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 ADD�SS:��r,�-tL �3� � I�uxtca CONTACT PERSON/PHONE: ' LOCATION OF SERVICE: �LL�'1�vQ. 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 ❑Reduced Pressure Principle-Detector �S„Double Check Valve C7 Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer ��CfA Model Number bDCZG Size � Located At�N1 VQ.uQ,}' � �51�Q Q��{Xp�Q,y� Serial Number �q 6�O��J5 Is the assembly installed in accordance wit manufact�ur r re ecommendations 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 ato�� psi Held at o`�`� ps' Opened at Opened at Held at Initial Test Closed Tight _ Closed Tight psid psid psid Leaked-7 Leaked�] Did not open ❑ Did not open ❑ LeakedCl Repairs/ Materials p P� Used �� '`�""I vu� Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight J psid psid psid Test gauge used:Make/Model In�� I{(.i�•�, S'� � SN: �(�"a7 a S� �P Date Tested for Accuracy: 1'� -3— I'� Remarks: The above is certified to be true at the time of testing. FirmName�-A ��rQ- �-��-3�Z��s�h�n�rm Address �o• D 74�'�($ �r7y Certified Tester(pr�nt) ��'^ � Certified Tester(signature) / Firm Phone# �( � �a�a '.�7� Cert.TesterNo.��bOP_S 3 vs Date /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 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: �J��(� �}{PX �� ay��Q.t,� CONTACT PERSON/PHONE: LOCATION OF SERVICE: _ YY�p. 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 ,-1Reduced Pressure Principle ❑Reduced Pressure Principle-Detector �Double Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer � P.�,I 6 e�. ,O�Model Number ��C. Size 3�� Located At �h �c�- � S ide af �I'01?P,✓�'vl Serial Number q� ol�'DU Is the assembl y installed in accordance with manu a u er 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�psi Held at�psid Opened at Opened at Held at Inirial Test Closed Tight_ Closed Tight psid psid psid Leaked�� Leakedf�I 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 U Closed Tight Cl psid psid psid Test gauge used: Make/Model �� }� '� SN: (�(,�0� '�> �(p Date Tested for Accuracy: ��, �� Remarks: The above is certified to be true at the time of testing. Firm Name ��'� ft�' D4►Mas�L�s�h��/Firm Address P� �t�ox �ys�� r G�o��'L,,� 7G�7f Certified Tester(pr�nt bi� � Certified Tester(signature) Firm Phone# � I7�'3a �557 �] Cert.TesterNo.��153�L� Date S �lo * 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