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2016_0318 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) � I MAfLING ADDRESS: �'1-S C�,h�� I J`i'�. �GOI"� P� CONTACT PERSON/PHONE: 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 ' �R uced Pressure Principle-Detector I Double Check Valve �'Double Check-Detector �� 1PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer �� Model Number � �� Size_� Located At N(A� (.OYI�1�/1� Q� �Y�W lih �A,I�I,Q�' Serial Number "! $� .�Q� 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 Opened at Held at lnirial Test Closed Tight�'� Closed Tigh �' psid psid psid Leakedl Leaked.1 Did not open f` Did not open ' Leaked' Repairs/ /� Materials � -�� � �K„/ � Used Held at psid Held at psid Test After Opened at Opcned at Held at Repair Closed Tight�1 ClosedTight I psid psid psid Test gauge used: Make/Model�i�,������� SN: ��,3 (�8 Date Tested for Accuracy: � 2'3''� � Remarks: The above is certified to be true at the time of testing. Firm Name��l" �L 1-� N-p0�Y1?_cS'f�c If.�S�-�irm A ddress `j��0 � � 7�017 Certified T'ester(pr:nt � � Certified Tester(signature Firm Phone# p�7'Z32- 'JrJ�7 Cert.Tester No. lJV'd(I ���/ro Date � �s-�(p * 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 I.D. # 0570040 (Customer) MAILING ADDRESS: �'� ��,f� �J�� � . 1'�'1Q�re �, CONTACT PERSON/PHONE: LOCATION OF SERVICE: �GvrkA� 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 ': R uced Pressure Principle I Reduced Pressure Principle-Detector � ouble Check Valve '��i Double Check-Detectar IPressurcVacuumBreaker 1Spill-Resistant Pressure Vacuum Breaker Manufacturer.��l?,Y��C.� Model Number �� Size 3� Located At Ul� 1� Q� ��/ Serial Number "L (�� Z-� Is the assembly installed in accordance wit manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Bre er Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �'� psid Held at��psi Opened at Opened at Held at Initial Test Closed Tight..l� Closed Tight � psid psid psid Leakedl I Leaked��l Did not open I I Did not open I ��� Leaked' I Repairs/ � Materials 3�� p�'�C� Used � Held at psid Held at psid Test After Opened at Opcned at Held at Repair ClosedTight I ��� Closed Tight� I psid psid psid Test gauge used: Make/Model ������ SI�: d d?���� Date Tested for Accuracy: �aZ"3'��S Remarks: The above is certified to be true at the time of testing. Firm Name l-��i����j�yto.S'�7C_. Firm Address ^ �� � Certified Tester(pr:nr) '� ertified Tester(signature) Firm Phone# �''17- �32-g�17 Cert.Tester Na��r��/yG Z Date 3 '� �' �� * 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