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2016_0916 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) � ,��b�,� MAILING ADDRESS: �� a( � r � CONTACT PERSON/PHO 2 � � 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 f ,Reduced Pressure Principle ��7R�duced Pressure Principle-Detector �� I Double Check Valve C�'Double Check-Detector CPressureVacuumBreaker I�-Spill-Resistant Pressure Vacuum Breaker t� Manufacturer G� Model Number �� Size Located At U�A-(•�IT Z�� L,�?��. Serial Number 1�' �� 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 Tight�; Closed Tight _1 psid psid psid Leaked� I Leaked �I Did not open ��;_; Did not open �I Leaked i�I Repairs/ Materials Used Held at + psid Held at � sid Test A ter � Opened at Opened at Held at Repair Closed Tight I Closed Tight I_ psid psid psid � 2 Test gauge used:Make/Model� I� SN: �✓(��7 Date Tested for Accuracy: � l � Remarks: The above is certified to be true at the time of testing. Firm Name ,��(.�Fd'L �6 IC1�' Firm Address��c� K�(.l`.Yl� r�� /lolC�O Certified Tester(pr±nt) �� -�"�Certified Tester(signature) Firm Phone# �� D�� Cert.Tester No.pT �� Date � 1� �� * 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) n '� MAILINGADDRESS: C�h6'� � ��hi��.s6�� CONTACT PERSON/PHON : 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 1Reduced Pressure Principle CReduced Pressure Principle-Detector :�uble Check Valve ' I Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �'�i "� Model Number Lz� -�V Size� Located At 1L�� 1�� Serial Number�� Is the assembly installed in accordance with manufacturer recommendations andlor local codes? �CS 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 Tight� Closed Tight ❑ psid psid psid Leakedl I Leakedl Did not open I I Did not open I Leaked.1 Repairs/ u�C,�� P� �� Materials �� ` Used �6{��A��(s�� ti 1�5�'�a%�,-� Held at psid Held at � sid Test A ter � � / Opened at Opened at Held at Repair ClosedTight I� ClosedTight`'T psid psid psid Test gauge used: Make/Model �� «i� SN: �� ld�`T�t Date Tested for Accuracy: t2 � C�¢ Remarks: The above is certified to be true at the time of testing. FirmName ��A� ��R� Firm Address�2"l �� `�" Certified Tester(print)�� '�Certified Tester(signature Firm Phone# �� G �aaa- ra� Cert.Tester No�f ��_Date (� « C� * 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