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2016_0111_RPZ IRRIGATION DOMESTIC FIRELINE �� The following form must be completed far 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: 13�� ° ��`� TCc CONTACT PERSON/PHONE: c� o �2—39 3-3Z 33 LOCATION OF SERVICE: j�S S .� �a,D The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operaring within acceptable paraineters. TYPE OF ASSEMBLY �Reduced Pressure Principle I-'�Reduced Pressure Principle-Detector � Double Check Valve CDouble Check-Detector '� '��PressureVacuumBreaker � �;Spill-Resistant Pressure Vacuum Breaker Manufacturer W��5 Model Number ��R � �/�G�� Size Located At �"�'�� f��1 uN�d�`'^��`�1 Number .�7Lq�3 � Is the assembly installed in accardance with manufacturer recommendations and/or local codes? �5 Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check ��1(-f b Held at �� psid Held at �� I psid Opened at �' ( Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked. I Leaked' J Did not open I I Did not open I Leaked ' Repairs/ Materials � Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight�� 1 Closed Tight i I psid psid psid r Test gauge used: Make/Model �`L(�-r�nS ��.-� SN. ��ugo 46`�— Date Tested for Accuracy: �l �'�L� Remarks: The above is certified to be true at the time of testing. FirmName �� r�-L��"�h� Firm Address �� Jx 2�� r `�"ef 1��+ I� 7��'z7 Certiiied Tester(print) ��V� ��n Certified Tester(signature) � Firm Phone# ��2 ,�� Cert.Tester No. P�o1Z7� Date � � � I��b * 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 l�l � 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 S S• /�P�-�W+ l�t� CONTACT PERSON/PHONE: ,�ch�v�-�S�S 9'ZZ-3�3"3Z 33 LOCATiON OF SERVICE: / 3 S' S. C n The backflow prevention assembly detailed below has been tested and maintained as required by commission regularions and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY �educed Pressure Principle '�Reduced Pressure Principle-Detector �-1 Double Check V alve �Double Check-Detector ��PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer w�� Model Number a09 �� Size �/Z �� Located At �✓��'��'� C�� Serial Number 3�3 S 3� Is the assembly installed in accordance with manufacturer recommendations and/ar 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�psid Opened at �� Opened at Held at Initial Test Closed Tightf� Closed Tight I� psid psid psid Leaked 1 Leakedl I Did not open I I Did not open I �� Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight[��1 Closed Tight.I psid psid psid Test gauge used: Make/Model ��-�f ��'� sN: � 3�q�`�6 Z Date Tested for Accuracy: �«—Ir Remarks: The above is certified to be true at the time of testing. FirmName 8iT ��IIdW Firm Address r��iY �7d��.S� 1��°yl`�1' �Uv�r�7�77 � , Certified Tester(prZnt) �� n Certified Tester(signature) �� Firm Phone# �� sv2- 7 �d� Cert.TesterNo. �/�'�1L7� 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