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2016_1026 IRRIGATION DOMESTIC V 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) F MAILING ADDRESS: � � , � el � T .7�(3t� 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 7Ij�educed Pressure Principle CReduced Pressure Principle-Detectar ��oubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker :�Spill-Resistant Pressure Vacuum Breaker Manufacturer ��'�''�"� Model Number L F�(��'� � (�rSize� Located At ��Tt'y� SaU�h �.'ITC�'RnCe Serial Number �v�-T'T� � 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��p Held at 1.�psi Opened at Opened at Held at Inidal Test Closed Tight� Closed Tight I � psid psid psid • Leaked I 1 Leaked I�1 Did not open .l Did not open .] Leaked f �� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Neld at Repair ClosedTight C 1 Closed Tight��=1 psid psid psid Test gauge used: Make/Model W R�'�I YL� �� SN: Q g �� (4�9 Date Tested for Accuracy: [-+��- ((p Remarks: The above is certified to be true at the time of testing. Firm Name��i „ /�(,�rFirm Address��,�(_ � � Pt c ��(j � ��,��"J�9 Certified Tester(print)� �v n��Certified Tester(signature) � � � Firm Phone#��t{-"Cp'�'�� Cert.Tester No��d�� Date ��o�Cp—�� * 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: � � �j"� � �j , � �( �� ']�a�,� CONTACT PERSON/PHONE: ' �LJ— j 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_ duced Pressure Principle CReduced Pressure Principle-Detectar C�ouble Check Valve ❑Double Check-Detector �PressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker r �Q��Size_ �� Manufacturer �PI� � Model Number � Located At l"1��pCL'�'Y'+�►�y�'�'�1C1�Serial Number ��T'tc��p Is the assembly installed in accordance with manufacturer recommendations and/or local codes? T '� 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�psi 'T�eld at�psi �.Opened at Opened at Held at Initial Test Closed Tight� Gosed Tight,� ��sid � psid psid Leaked�.�] Leaked❑ Did not open [ '�� Did not open [�; Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight f_� Closed Tight� I psid psid psid Test gauge used: Make/Model VY I I�1 II'�i��j SN:�j �� p�9 Date Tested for Accuracy: � ^��-�(P` Remarks: The above is certified to be true at the time of testing. Firm Name�rlSF�OC�Hc��w•� Firm A ddress�,�,�.�3�� e�1� r 1�` T�(,�]�� Certified Tester(pri nt) t Certified Tester(signature) � Firm Phone# �1�' �� a1 Cert.Tester No�� /�� Date �Q�v��(� * 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