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RPZ_2015_1027 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: � 3 03 l�rct►� 1�;,� ��,�. � 1 � �)C CONTACT PERSON/PHONE: �-o u i b �cic i a 5 �� `� - 5�o-- O `F U LOCATION OF SERVICE: I�-U ak�� �� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operaring within acceptable parameters. TYPE OF ASSEMBLY � educed Pressure Principle I��Reduced Pressure Principle-Detector �ouble Check Valve �� IDouble Check-Detector -1PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �G2.-�-�-5 ModelNumber L-� ����1 Size 3,, Located At Fva��J u.�� �o n C:C55 i �n �11C� Serial Number �4 Z�b3 �3�rj 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 lnlet Check Valve 1 st Check 2nd Check Held at �a�� sid Held at p id Opened at Z�� Opened at Held at lnirial Test Closed Ti ht Closed Ti ht psid psid psid g g Leaked ! Leaked 1 D�d not open ' Did not open f 1 Leaked Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at � Repair Closed Tight f Closed Tight I_! psid psid psid Test gauge used: Make/Model Co m br�Lv y(�- ZOd\�L SN: Z`�g'nt�0 Date Tested for Accuracy: �'1 ( Z5 I 1 S� Remarks: The above is certified to be true at the time of testing. Firm Namel�PP��1 �5 p Firm Address i�� ��r`o��1 ei� ��r �I � Certified Tester(print) � � Ct t �'� Certified Tester(signature) � � � Firm Phone# Z�� "�{.�la ���Q Cert.Tester No.�P[��(��]S�Date �C� �7 I� * 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 LD. # 0570040 (Customer) /� MAILING ADDRESS: � 3 �3 l.� i�-►1�1P�' l��r , �.p PpQ� � �X CONTACT PERSON/PHONE: i� 1'In�ra`�t Zl�{— SlGJ'� ��D�b LOCATION OF SERVICE: � ZO IJo�-��, �•-, j�a� 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 �educed Pressure Principle ��Reduced Pressure Principle-Detector [J Double Check Valve �!�Double Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer VJQ��-5 Model Number �--���-3 �� Size 3��}'� Located At �E�a-t��r ���C'.1a �ceS�lOf� Serial Number �Z�� 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 ��psid Held at psid Opened at 2� (� Opened at Held at Initial Test Closed Tight'� Closed Tight ! I psid psid psid Leakedf 1 Leakedf' Did not open I J Did not open '� I Leakedl�� 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 �►^n brACO ��'Z��K SN: Z5$�Ch� Date Tested for Accuracy: � �Z`�' I 1 S� Remarks: The above is certified to be true at the time of testing. Firm Name�-O p(a��1 J— ,S,o . Firm Address ���3 W �{` �p � (� Certified Tester(print) 1 le� Certified Tester(signature)_���� Firm Phone# Z�'t ����a�b Cert.Tester No. I�I d�O�J�U Date r2� j� * 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