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RPZ_2015_1112 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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) � \ MAILING ADDRESS: �3 03 W`('Q f� ��r• CONTACT PERSON/PHONE: ei�.9�S �c�l S 'Z�4-�g(P�- d (� LOCATION OFSERVICE: 3Of� Gl��t'� i (.,n• 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-Detectar �Double Check Valve �Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker �� Mo 1 Nu �b � Size Z�� Manufacturer � �� Located At t'�Dh� Of �c-�� ` Serial Number � d� bb 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 Neld at �� I psid Held at �' �psid Opened at Opened at Held at Initial Test Closed Tight�j Closed Tight y? psid psid psid Leakedf 1 LeakedCl Did not open I I Did not open _] Leaked f 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTightll ClosedTightCi psid psid psid Test gauge used:Make/Model �/�'► �/'0�-� 7"�p-�D�SN: Z��d�� Date Tested for Accuracy: � � C�J� Remarks: The above is certified to be true at the time of testing. �+ � r, l � Firm Name �!/ -'� �� Firm Address � �� "�a� �Y /� � � Certified Tester(pr�nt) Q I�� i�� Certified Tester(signature) � � �-��v � DG��75� /l �- /�' Firtn Phone# 2 `�- � 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 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 1.D. #0570040 (Customer) ,.l MAILING ADDRESS: � �� W hQJt Q✓ �i�✓� CONTACT PERSON/PHONE: euli� j j,�s / — � O LOCATION OF SERVICE: OO ' � � 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 CReduced Pressure Principle-Detector '�ouble Check Valve �Double Check-Detector 1-iPressureVacuumBreaker I 1Spi11-Resistant Pressure Vacuum Breaker e ,, Manufacturer ��'6(� Model Number �� Size � Located At_ �r� p� S G-��p� Serial Number � ��JS� 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 �` 7 psid Held at Z=Opsid Opened at Opened at Held at Initial Test Closed Tight�4 Closed Tight��k psid psid psid Leakedl�1 LeakedC.� Did not open �I Did not open I I Leaked'i�� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight I-i psid psid psid Test gauge used: Make/Model�bn'`�-� �d ` �-� � SN: 2-Sg�� Date Tested for Accuracy: 9 /�S �S� Remarks: The above is certified to be true at the time of tesring. � � -// Firm Name�bD�l/ --�� Firm Address Q� �/1`Q i�ir � ` Certified Tester(print) 1 a! Certified Tester(signature) Firm Phone# !� 7 �q�p'�J�/7� Cert.Tester No. ��7-�D Date f< /� �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