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2016_0908 , �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) � MAILING ADDRESS: 3 r' �-�i � �S I 9 CONTACT PERSON/PHONE: �'z%-�i s �� — 4 �o- �0�b LOCATION OF SERVICE: W rct ',• 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 1Reduced Pressure Principle-Detector �'Double Check Valve -1 Double Check-Detectar �PressureVacuumBreaker -'Spill-Resistant Pressure Vacuum Breaker J �� Manufacturer Q�•f� Model Number ��/�� Size 2 Located At �4� b"f �o/►'�,� Serial Number A `T I 3�� Is the assembly installed in accardance 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 2� � psid Held at Z�O psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight'�b[' psid psid psid Leakedl I Leaked. I Did not open i�I Did not open I I Leaked �I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I 1 Closed Tight I-=1 psid psid psid Test gauge used: Make/Model � b/' CU ''7`'0-�ap 'T/� SN: �� Date Tested for Accuracy: g �8 ��r Remarks: The above is certified to be true at the time of testing. Firm Name ��+ -'— S�� Firm Address � �03�"�r�n �' �✓ Certified Tester r:nt a U�� , (p � ) / Certified Tester(signature) Firm Phone#��—��`�d �� Cert.Tester No.�J�ODU6�J' g 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 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: I��3 (�rQ r e ,�� CONTACT PERSON/PHONE: Lew i'S G a Z/`f-�/9�-- D 6 LOCATION OF SERVICE: 3 D I pn Pr ',� ' 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 C�Reduced Pressure Principle-Detector �ouble Check Valve C1 Double Check-Detector ❑PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker Manufacturer 1��'�'�5 Model Number aa�- m 1 � Size .�� , Located At I� ►�C�2�'1 Serial Number f� 2�'�g J Is the assembly installed in accordance 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 Held at Z�� psid Held at Z�Z psid Opened at Opened at Held at InitialTest ClosedTightfj� ClosedTight� psid psid psid Leaked. I Leakecf� Did not open .1 Did not open l Leaked' Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight�.7 ClosedTight L I psid psid psid Test gauge used: Make/Model bt'GiGU '7'�"2'po� SN: ZS SOO� Date Tested for Accuracy: �� Remarks: The above is certified to be true at the time of testing. FirmName el l �—�� Firm Address �3d3W1"(� l �r C�, . e11 �-�c 75U19 � �� .FI �� Certified Tester(print) 0�� Certified Tester(signature) Firm Phone# �--�7`�l� C)�`7`� Cert.Tester No.UI��i�s�j 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