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RPZ_2016_0205 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) MAILING ADDRESS: �8 e � I'� � I CONTACT PERSON/PHONE: � - LOCATION OF SERVICE: � The backflow prevention assembly detailed below has been tested and maintaine as required by commission regulations and is certified to be operating within acceptable parameters. ,� TYPE OF ASSEMBLY �"Reduced Pressure Principle CReduced Pressure Principle-Detector ��JDoubleCheckValve ❑Double Check-Detector CPressureVacuumBreaker :7Spi11-Resistant Pressure Vacuum Breaker Manufacturer �( 1 1{� Model Number 9�� ( � Size ya�, �C i ficherl,�1e?c-� Located At �'' P► � �� . ` C Serial Number ��9��D(� Is the assembly installed in accor ce 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�p�d� Held at .�Q ps' Opened at �_� Opened at Held at Initial Test Closed Tighti'� Closed Tight �� psid psid psid Leaked�] Leaked❑ Did not open I I 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�, Closed Tight C.I psid psid psid Test gauge used: Make/Model ��i��ilr1� / I C7Z� SN: Og � Q�� Date Tested for Accuracy: �-��•"�(�O Remarks: The above is certified to be true at the time of testing. Firm Name j ��-�� /1 1�(�r-Firm Address r"�•��i�.�C?T�� ` v�6��x�(�,<� Certified Tester(pr:nt) � ' � Certified Tester(signature) Firm Phone#_��-t"��-9��'3 Cert.Tester No. ��7(,J'T" Date �"�—��Q * 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 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 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: (,,.. - (p• � 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 �!Reduced Pressure Principle ❑Reduced Pressure Principle-Detector �i Double Check Valve ' ]Double Check-Detector �PressureVacuumBreaker lSpill-Resistant Pressure Vacuum Breaker Manufacturer (�j'"t"'�s Model Number �� 1 Size � Z+� Fir�l�►��/11C.t,t3�Corner , /� /- Located At 1' Serial Number '9��T�c�! Is the assembly installed in acco ance 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�p ' Held at •o�ps' Opened at �' , � Opened at Held at Initial Test Closed Tight_� Closed Tight � psid psid psid Leaked I Leaked C I 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 f� Closed Tight�__I psid psid psid Test gauge used: Make/Model V�4� 1 j 1�S �r7Z� SN: �g (�� (�rj q Date Tested for Accuracy: ��7�-�[1J Remarks: The above is certified to be true at the rime of testing. Firm Name�i �I�R ��YIl:1�Firm Address�(� .�`��i � � � P,��jS�Cj ��['�^�('Z'rjr�j Certified Tester(print) � � � Certified Tester(signature) ` Firm Phone#��-[o�'rj'�� GL7 Cert.Tester No,t�x�_Date� �� —l� * 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