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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 PREVENTlON ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS:�(�(J� �Q (►�'� �� (,(J ,( CONTACT PERSON/PH NE: LOCATION OF SERVICE: � YY�f� 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 C Reduced Pressure Principle �R�ced Pressure Principle-Detector C�^'�e�t�uble Check Valve -��'Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer�1U��5 Model Number �,�A �� Size� Located At � Serial Number �_� Is the assembly installed in accordance with manu acturer recommendations and/or local codes? P 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 psid Opened at Opened at Held at Initial Test Closed Tight�i Closed Tight ❑ psid psid psid Leaked�l Leakedn Did not open � Did not open I�J Leaked�'�� Repairs/ #a ��3 � d �" -}�S� lo c�C. �'1 tt.�� '��'�5 ���..o� `h^c„'� ,,�o.^ ��' Used ials Co"^"C fl'^.�-� ( d' �i'�- Va� �S �to.(L�� q (.vo� '-� s�. i-' �f'F Held at psid Held at psid he� Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model �Ni��-��^� �f SN: O(�o?�S�w Date Tested for Accuracy: !a"3' I S Remarks: �1 ���" c�-.s,c. -�o '��-�9-- , �o'-�� 0 �c�'2�,�N,r� Jt,u� �}— The above is certified to be true at the time of testing. FirmName �-� '�r�. k �o�»�� �s6k�irm Address II•0 " aax ?�s��g ��' (N°''�;7)c�(��Z� Certified Tester(print � �� Certified Tester(signature) Firm Phone#��7�'SS 7 7 Cert.Tester No.���� ����� 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 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 recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) /�� � � Q MAILING ADDRESS: ��)►'1 �,Y 6'L4S�'(!'Ue� 7�(L, d�(pS ���,Yk I CONTACT PERSON/PHONE� LOCATION OF SERVICE: , rn 4 _ 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 �pouble Check Valve ❑Double Check-Detectar �PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer(/�JQ�S Model Number ��rn � Size '3� Located At �y1_��-��jw ) � OY Q�_q e ia �ii nber 4$Z.� Is the assembly installed in accardance 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 psid Held at psid Opened at Opened at Held at Initial Test Closed Tightn Closed Tight � psid psid psid LeakedC7 Leaked❑ Did not open n Did not open ❑ Leakedn Repairs/ /I Materials �� `�' �`i -`'C.S� Cd�LS �l �. �e.r�o�,iS �� w� •.{-t�.,�{- o� �-'- Used �i �Q p�� 1 e � Held at psid Held at psid Test After Opened at Opened at He1d at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used: Make/Model�N� ��^�^� '�Zi� SN:O��7�� �� Date Tested for Accuracy: (� '� -I S' Remarks: The above is certified to be true at the time of testing. FirmName ''/}�j�� � �,�1,� �.s�l-+�v Firm Address P v. aox ?�Sy�:�tr�'I��Y�%7( 7G�?�j Certified Tester(pr�nt) �► � �-✓ Certified Tester(signature Firm Phone# � ��",�b' S S`'�� Cert.Tester Na �Qa J �SS�1 Date � I 4 � * 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