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2016_0115 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 COPPELL PWS LD. #0570040 (Customer) ,�,j.-e -}��,� �� MAILINGADDRESS: �ZO SD��''G1WC.�S .�'V► �I�VGI CONTACT PERSON/PHONE: LOCATION OF SERVICE: , Yy�� � 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 _7Reduced Pressure Principle-Detector �)ouble Check Valve �Double Check-Detector ��PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �"�g Model Number (��� � Size d� Located At� rt�1 y irp/yN��Yy�p t.�, Y�Ory1 Serial Number ��s oq a- 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 at�psi Held at�psi Opened at Opened at Held at Initial Test Closed Tightl Closed Tight ._ psid psid psid Leaked�1 Leaked'�-J Did not open C1 Did not open �J Leakedn Repairs/ Materials Used Held at psid Held at psid Test After � Opened at Opened at Held at Repair ClosedTight�l ClosedTight C:I psid psid psid Test gauge used:Make/Model Wt �I��nS I �7 SN: �(0O? °5� � Date Tested for Accuracy: _� Z 3 ' /� Remarks: The above is certified to be true at the time of testing. Firm Name �'�htG �' �s�Q��Firm Address�o . �x 7�S'�� 1'�✓r�No✓�,��(�f'��j � Certified Tester(pr:nt �1 n /�o Certified Tester(signature Firm Phone# �f?'a�d '�577 Cert.TesterNo.P�OoIS 3� < Date 1 /��/ * 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 a.3 sw IRRIGATION DOMESTIC V 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) ����41'� � MAILING AD�RESS: 'JrZp 50�V11'e3-�1�l�1 �I V d 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 ❑ duced Pressure Principle ❑Reduced Pressure Principle-Detector ��ouble Check Valve ❑Double Check-Detector 7PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �Q�'S Model Number ��� !'Yl c'� Cs�-� Size� J�H wa,-t,� 0�5q7 Located At N.� . �pr1�Q.(r Lh '�� b0.:U Serial Number 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 at�• t7 psid Held at�psid Opened at Opened at Held at Initial Test Closed Tightf� Closed Tight � psid psid psid Leaked 7 Leakedl i Did not open ❑ Did not open C� Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight I J psid psid psid Test gauge used: Make/Model ����I,�S I(J� SN: �(Q�7��� � Date Tested for Accuracy: �a1 �3 ` �� Remarks: The above is certified to be true at the time of testing. Firm Name I' ��i`/Z ��asf1[I�s'h�II irm Address Q0.�o�C 7HS`����"��9✓/'�..%�C 7��7�'1 Cerrified Tester(print �h�'�-o Certified Tester(signature) Firm Phone# ��? �a3� '��7 � Cert.TesterNo. �P00)53�� Date ���� C� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy