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2016_0821 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 LD. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: � a LOCATION OF SERVICE: "� E? - 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 duced Pressure Principle I 'Reduced Pressure Principle-Detector ouble Check Valve ��Double Check-Detector lPressurcVacuumBreaker !�:Spill-Resistant Pressure Vacuum Breaker ^lM il Manufacturer �t/"1 "�s Model Number��d� 1 �� Size� Located At �n �f�U ��"��' �� Serial Number � �c� �� / Is the assembly installed in accordance with manufacturer recommendations and/or local codes? T� �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 Inirial Test Closed Ti � I Closed Ti t I I psid psid psid Leaked� Leaked'� Did not open 1 Did not open I Leaked'' I Repairs/ �i�S h � i Vl�_ l�i��' s R Y�'r��5 Materials Used c��fline0� �� '� h CC�S Held at psid Held at • psid Test After � Opened at Opened at Held at Repair ClosedTight L+� ClosedTight'�� psid psid psid Test gauge used: Make/Model�j f�i►��-�� SN: �g ��[��j� Date Tested for Accuracy: ��.7- (� Remarks: -�F �v��-{-F}(� CA-�,S c,n �'PS� Cb . . S The above is certified to be true at the time of testing. FirmName�lS��1��C 1.q(J1S►',_ �l��rv�Firm Address ��U �,��L9"�� LC(".P,1,i�1/i��C'. �.�?�'� Certified Tester(print) �/ Certified Tester(signature) �`I � Firm Phone#��`f " �'�"�� Cert.Tester No�f��(� Date � - � � -�(D �� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS c5"'.2 I "' ��P **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 I.D. #0570040 (Customer) MAILING ADDRESS: 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 I iReduced Pressure Principle ��duced Pressure Principle-Detector -]Double Check Valve ouble Check-Detector �PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker ,� �, f K Manufacturer vY F��-'�S Model Number7 'r17�,'�A -�� Size Located At �r1 � f�U �� Serial Number � � �� 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 Initial Test Closed T' t��l Closed Ti �t � psid psid psid Leaked� Leaked� Did not open ��I Did not open ❑ Leaked� Repairs/ Fl� �'Jh� s `L'-YV�C� C �P� ��AVJ 5 Materials Used �l e��C� 1 � �'� C eC1G5 Held at psid Held at�1 psid Test After Opened at Opened at Held at Repair Closed Tight�� Closed Tight� psid psid psid Test gauge used: Make/Model i LK 1 ►��_T�'�� SN: 0 g �-Q ��S��1 Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Firm Name 1"li_ ' �L�,J�/sh! ,.�irm Address 1-1 J'��.�L��9� � �e.�.Ll J��"j1/��eTX i� 1 Certified Tester(pr:nt)��Q11 �1��Certified Tester(signature) � Firm Phone#��^�� `1�Z �� Cert.Tester No�PC�^X��7V`� Date g- � �-��o�� (��M f�� * 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