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2016_0304_RPZ IRRIGATION DOMESTIC � 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) Ma1i,iNG aDD�ss: �1�I� w� �;+1�,� Q.cl , �PPe-�I F`rtX �s o 19 CONTACT PERSON/PHONE: �!�2 y�O2. o I O 1 LOCATION OF SERVICE: �IH`I W 3e-�-1-�e,l R� 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�educed Pressure Principle ��1Reduced Pressure Principle-Detector f 1DoubleCheckValve :-7Double Check-Detector �PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker Manufacturer ' � l � Model Number �P�F� p Size �„ Located At ��0�► CS�� �w`� Serial Number ���`�'Z- Is the assembly installed in accordance with manufacturer recommendations and/or local codes? `�e.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 �'} psid Opened at� ' � Opened at Held at Initial Test Closed TightN� Closed Tight C� psid psid psid Leakedl' I Leaked� idnotopen [.7 Didnotopen '�J Leaked��l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight f l psid psid psid Test gauge used: Make/Modelm V'�V��'C' I lJ'►� `5���� SN:���- !� /� Date Tested for Accuracy: �� I t- I� Remarks: The above is certified to be true at the time of testing. FirmName �VG��I� Firm Address �01 S (Q�lr �� ► �5��� I Certified Tester(print)�ou(a�(�5 � ���� Certified Tester(signature) Firm Phone# ��j� �� �� Cert.Tester No.�P�2� /3 Date 3 9- 1 �O * 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 N 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) �fIt MAILINGADDRESS: - 1'T � w ��-��� � r C�o��-II,Tx ����� CONTACT PERSON/PHONE: �I'�� � o►O I LOCATION OF SERVICE: LI`-I� w J��e.-�-I-.Q.1 1C_r�I 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 '�Double Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker n � Manufacturer Tt��lo Model Number �Pr--� � R Size � 2 Located At in ki-k.l�e,r � �G V'c=�c-��- Serial Number� �'g � S� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Y 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 s' �psid Held ats � psi Opened at 2 '� Opened at Held at Initial Test Closed Tight� Closed Tight psid psid psid Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model �'G�w�'S� I����S—�'�� SN: �� 6 G b�2�'> Date Tested for Accuracy: �'1� ��` �s Remarks: The above is certified to be true at the time of testing. Firm Name �1/��t�C�"� Firm A ddress �O� 5 � G" ���� �c� �� I 0� Certified Tester(print) ��c,s������� Certified Tester(signature Firm Phone# ���S� �� �v Cert.Tester No�P�2S�J-3 Date�`1 b� 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