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2016_0907 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: C�e -�1i `T-�ac� C�e��.r' ��'`S �ci'1�4`S�'�-,n�5 � S-it� F�c�;S�si�CK75�� CONTACTPERSON/PHO ` h�s `� irS ��'-� � c LOCATION OF SERVICE: " � ' � f2 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 iReduced Pressure Principle CReduced Pressure Principle-Detector �-1DoubleCheckValve I�ouble Check-Detector 1PressureVacuumBreaker i-'Spill-Resistant Pressure Vacuum Breaker Manufacturer K �JC c; Model Number �� Size �� Located At �/�i�� tC1:`/�2� Serial Number IV �'�F 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 � lnitial Test Closed Tight' i Closed Tight � psid psid psid ��(,, Leakedf�1 Leaked.1 Did not open f�_I Did not open I I Leaked��1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight LJ �ClosedTight I psid psid psid Test gauge used: Make/Model W ��'k-��5 ��C.`� SN: �j1�� Date Tested for Accuracy:y��—��s, Remarks:i1,, ;�� '�a ��,�- •��TS•}- C e L� ; f,.�G�-}Pr _�=-�c��f �OC i< �� k- c�i S�S � i��e The above is certified fo be true at the time of testing. FirmName .1r�c'Glr ��.f�. Firm Address (.��1[.,, r n,• . , ;�� T�w''��('llail' /7_ Certified Tester(print)�fC1V.� ��y-l�r�l� Certified Tester(signature J �2�..1, �.(.�� Firm Phone#�� '�.�--'��i � Cert.Tester No. ��• `it{��y 3 Date ` 7—� • * 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 � "I�hc following form must be coin��lcted t��r cach a�scmbly lesl�ccl. ,A :;i��n�cl �ind dal�cl origin��l must be submitted tu the ��ublic �v;i(�er su��plier for recordkcc:E�in�� ur��oses� 13ACKFLON� PRE��'ENTION ASSF M131_,1'7l?S'1'AND MAINTI:NANCE RGI'ORT NA[��L OF r�wS: CiTY OF COPPCLL PwS l.l�. # 0570040 (Cuslomer) . n�if�ii_�Nc n[�r�rz}�.ss:fs��,�--1-.-�rc��ti�t-- `5 �t��r �� _��5 �_�3c_�1'��Sc.�i�( `7Sut,i CON�I'ACT P[;RS()N/PI-ION�;:__� er�_.��.�}�� _._�1• � �-� "��% --- LOCATION OF SER�'ICE: '�GC% '�!'utS� _SC'�T_�7�L -�-�— -- — ---- 'The backflow prevcntion asscmbly detailed bclow has been teste�l and m�int.�ined as rcquired bv commission rcgulations and is ccr•tified to be oper�ting within ncccplahl� p�irarnerers. T�YP[: OF ASSrMI3LY �ducecl Ptessure Pri��ei�le Reclucc�d 1'icssure Princi�le-0ctector �ubic Ch�,ck Valve Douhle Check-T�c tector : Pressur�Vacuum 13reaker Spill-Resi�t�:inr ('ressure Vacuum Brcaker --' � � �C Manufacturer-- � � __ Model Number � _�_4_�. _Size y ___ L��c��t�d At_��'�k��_..�3�' �S'2�"� --- �crial Ntimb�r __�'�A_ :��. Is [he ass�mbly installcd iri��ccoi��l��in�e ��vi�h manufacturer recominenilati<�n� and/or I��cal codes? � � S _ Rcdiiccd Pressure Princi�le Assemblv Pressure Vacuum 13reaker �ouble Check V�Ive Assembly RcIieFValvc Air fnlet Chcck Valve I st Check 2nd Check 1 r-'+� Held at psid Held al psicl O��ened,at - --_- Openrd�rt- ---_ Fleld at -- lnitial Tcsl Closed Tight��'� Closed Ti��ht '�� psid ��itl psid Leakcd '�� Lcaked� I Did not o�>en � I�id not upen � Le,.ike�i Repairs/ Materials lJsed fleld �it _ ��sid i-lel�1 a[ ��i�l - -- -��- - l e5t Af��r �)��cnc�i ,il _ _ ()��c:ncd.il _ ---- I lel�1 tir ----- ReE'�:iir Closcd�l ighl Clcisc�l l ighl �,�id �i,;i�i ��sid Tcst aiit,� use,d: Makc!Modcl__'IN'�11E-s�� - SN: _�_�.�;.�� i. � `7 T' � �} _. — . . ._...____'—._ ....__.__._—.. __ . .. — _._---- - _ Date Tested f�or�ccuracv: "`�^��-t�. � � - _ � ��-- i Rema rks:�12��` . �i.�y" 1L2_1a��aer �-�-5��5 c�_�_�_.__��L��L1��C`I c�.� �-eccl �� ;��c�_�_ `� ,�_��_s� CCC.�S-- - --------___--------- The above is certified to be truc at fhe limc ot�tesrin�. I�irm Nainc.�aLt�.�a f� --------f�irm AddreSs ��3_�111�,L_�:Y�'��__�l �� 1fa71�� 1 /JwrI . . \ e'-' ' a � _!�� Ccrhticdfi�cstcr(I�r,ntl��ti,.�_S�'�� Ccrtitic�i �cster(�i�n,it�ire}-_��'i Firrn Phonc �'_�_�lr�,�'1c�� ---. �-�crt. l c��lrr 1��.��41�L,`(_3_----L)atr � -']' f�, * TEST RFCOI'ZC)S MUST 131; KF�,I''T' FOR n"I� I I�..�Sl��l IiIZI��I: Yf�:;�IZS ** USEONLY MANUFAC�I'I,iRER'S RI.;I'LAC1;MI�;NT 1'AR"I�S White- City Co��y �"cllo�v- Cuslon�ier Ct��v Pink- �fc,ter's Copy