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RPZ_2016_0224 IRRIGATION DOMESTIC � FIRELINE ��Z 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) �r�.5 MAILING ADDRESS: S� � o tr1 CONTACT PERSON/PHONE: IYI oyS�c.- (o - � - a''S 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 f-Reduced Pressure Principle-Detector -1DoubleCheckValve I iDouble Check-Detector �PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer YV1�'�TS ModelNumberQ��_�,�, Q�'r Size_,� Located At Y'��cQ�J1�� Q,b Serial Number �� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? `�l S 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��3-psid Held at��psid Opened at a,� Opened at Held at Initial Test Closed Tightl� Closed Tight I� psid psid psid Leakedf Leaked[.1 Did not open ' I Did not open I Leaked..l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight'� I Closed Tight! I psid psid psid Test gauge used: Make/Model W�Ik)ns �'s sN: a.�1laaR� Date Tested for Accuracy: `�-fi� 1a/� Remarks: The above is certified to be true at the time of testing. FirmName 11� QCJ1(�,Vu(`Ol�` Firm Addresso�� IQ�d Q Q•(Jr'� �S� Certified Tester(pr�nt) GVCYI Certified Tester(sig� re Firm Phone# 9�a'3.j9'�(�� Cert.Tester No. � ��p�3� Date -a` ' � * 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 pC 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 I.D. # 0570040 (Customer) ` la�t`-� MAILING ADDRESS: �'O CONTACT PERSON/PHONE: ,�irh '�2p npvy .�'j(,y - � S-- 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 acceptablc parameters. TYPE OF ASSEMBLY ��uced Pressure Principle � IReduced Pressure Principle-Detector !��iDoubleCheckValve �� Double Check-Detector !PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �GL`�TS Model Number �� I1�/� Q� Size o?" Located At ��ri�A,O�,I�( Serial Number L�35b�- Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y a S 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 $'�(P p�_��s/id Opened at 3� Y Opened at Held at Initial Test Closed Tight.� Closed Tight �T psid psid psid Leaked' ' Leakedi I Did not open ' 1 Did not open ' Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight l i Closed Tight l i psid psid psid Test gauge used: Make/Model 1V�'�� G'S'� sN: ��i�aa9a, Date Tested for Accuracy: ��` '�0/S Remarks: The above is certified to be true at the time of tesring. ( i �f f FirmName � l� �{��a�"�� Firm Addressa� �� ([ �' C/ C�il�' � �� Certified Tester(pr�n CU'{'h Certified Tester(signatu Firm Phone# ��339�l�� Cert.Tester No._��p3� Date ��O�y '��p * 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