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2015_1201 IRRfGATI'ON DOMESTIC FIRELINE�� y The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier far recardkeeping purposes: '�, BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT ' NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) � ' MAILING ADDRESS: �, CONTACT PERSON/PHONE: ' LOCATION OF SERVICE: "` c,olcs it�y��l l.r� '�.o pP�'�� , The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified ta be operating within acceptable parameters. TYPE OF ASSEMBLY ' C Reduced Pressure Principle ❑Reduced Pressure Principle-Detectar C�oubleCheckValve �1Double Check-Detectar � ❑PressureVacuumBreaker i�lSpill-Resistant Pressure Vacuum Breaker - -� - Manufacturer ��,�5 Model Number CC�C`1rj (w� { Size 3� I Located At Vc.��� �p.� RC�� Serial Number �O 5 3� ' Is the assembly installed in accordance with manufacturer recommendations and/or local codes? - I Reduced Pressure Princi le Assembl Pressure Vacuum Breaker I I Double Check Valve Assembly � � Relief Valve Air Inlet Check Valve 1 st Check 2nd Check I Held at��ps� � Held at�psid Opened at Opened at Held at � �, �Initial Test Closed Tight'� Closed Tight I_: psid psid psid � Leakedf� Leaked❑ Did not open C Did not open ' i Leaked I j Repairs/ Materials Used Held at psid Held at psid � Test After Opened at Opened at Held at � � � i Repair ClosedTight � ClasedTightL�' psid psid psid � :,- ., ���C+"Z.cac�� I Test gauge used: Make/Model �a r-���-C t-,_ SN: � S" �c3 S�' o� � Date Tested for Accuracy: / z^ �' "' / � Remarks: The above is certified to be true at the time of testing. � � Firm Name t.,..1c 3�r�+n 5��.�ca rc��c P�,�e�.Firm Address rf?�� S � . l,Jc�ct��c�,� �c,t� Qrcuti c.��t�c T�c ?S,eS„2 � �''� ��., �� � Certified Tester(pr�nt) ��� � Certified Tester(signature) � ' ''� ` Farm Phone#t`J�4 tU3�-i-754,,� Cert.Tester No.Vr��/��Date 1� -1 = IS * 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 �� � � ,� � IR�IGATION 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: � � � � B�1�K.FLOW PREVEN.T.ION ASSEIVIBL7�'TEST AND 1VIAINTEN�►N��,,R�PORT , " ��. , � _ � ^ ;��:N��;�-OF PWS:--GIT��iF C(�P�'�LI:� "��'WS ��:D..#�0�70(�'40 � �,� � '" (Gt�tomer)� � ���, �� . • � �, � � -�,., ' �AvfAILIl�TG A��RE,SS: � ,� „ . . .. ;, , i ,R, ,,, �� � ,' :�CONTACT PERSON/PHC�NE: ` _ ` LOCATION OF SERVICE: rj�-w.r,�e S y4y Q�,����� CoP�e�TY 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 i �ouble Check Valve C Double Check-Detector �._. �- �I Pressr'�-e�ac�urrt�i"ial�e�'--.-- � ' .rt�i�pi�l=�esTstant'Pfessa�e W�Cuu�-B�eaker _, .. , . . _., ..._. ___. i� Manufacturer W a�S Model Number ��Q1 Size � Located �t V�v�� bs� �o�d Serial Number 1�S 1 c�7 � 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�alve � �` Air�fnlet;� ��heck Valve , �� � 1 st Check' 2nd Check � �i < F �I . Held a���� � �=p}si� �eld a���psid Up��ned at Opened at �- • �eld at � °� Initial Test� �:,Closed Tightl�' Closed Tight C� psid psid psid �I Leakedf 1 Leakedl� Did'nofiopen �7 Did not open ' I' Leaked' I �.' Repairs/ � , Materials Used Held at psid Held at psid Test After Opened at Opened at Held at �, Repair Closed Tight'_J Closed Tight.1 psid psid psid � _, : . , ,. D _ . d f p�2 ck a/�' , T e s t g a u g e u s e d:M a k e/M o d e l �"`b��` '� S N: ��r� �� � Date Tested for Accuracy: ! � "��'" ��� � � � Remarks: �' ,., ting, , ,: %' ,. The above is certified to be true at tl�e tirne of tes � � : ,� _ �� � � � '., � � .,..'���m�la�ti�e ��'��tc'�.+�: �"�4c.-�es.�•Q� Firm Address 3'�l� 1.,�. �i2�a�c�C �s���, � .,,,' �» �,. (�c..,t�`�, '�r�?�,,.n:� T '7:�„"� .. . , � � �`" � ��� �� :; � � �� � � Certifie '�C'�� �� � .� ,.,�; . '��ttified Tester r;nt /�,�- � �`��f ti Tester(signature) � '��� � ,� ; �'irm Phone# � i�) b 3�1 r15(Q 2 Cert.Tester No������Z/�� � Date Io'1 - 1 - t�� '� : �].. * 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 '