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2016_1014 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: �'O � `I � CONTACT PERSON/PHONE: �/r.. � o"l �j LOCATION OF SERVICE: a The backflow prevention assembly detailed below has been teste nd maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY educed Pressure Principle ❑Reduced Pressure Principle-Detector Double Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker � (�t�o� l� ( Size �o�'�� Manufacturer � A S Model Number Located At �lI� ' �C.2 �/�ial Number�(7� � 1 Is the assembly installed in accordan e with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Brea er 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 �� Leaked'� Leake �� Did not open ❑ Did not open [7 Leaked❑_ Repairs/ Materials � Used Held at sid Held at T st A er p � psid Opened at� Opened at Held at Repair ClosedTight� ClosedTight psid psid psid Test gauge used:Make/Model l,� �����t��_��� SN: 65 I �Cl'���, Date Tested for Accuracy: , �`-� � Remarks: The above is certified to be true at the time of testing. FirmName ' �(���_�Firm Address �� �t-� �p� � �� �`,-�� a ( � j�,, �ncc�n v�I � � �3'� Certified Tester(print)�'l`�����`�ertified Tester(signature) Firm Phone# "l l� 1��— l�� Cert.Tester No.�(��lo'�� Date C7-- — * 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 LD. # 0570040 (Customer) MAILING ADDRESS: `O C.-� • � CONTACT PERSON/PHONE: LOCATION OF SERVICE: 2 The backflow prevention assembly detailed below has been tes and maintamed as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY duced Pressure Principle ❑Reduced Pressure Principle-Detector Double Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker 17Spi11-Resistant Pressure Vacuum Breaker Manufacturer ` ��.� Model Number ��1(.�� Size �� Located At`�.n V 0.���� (�C�L Serial Number�_C���S� 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 O '�psid Held at�psid Opened at� Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked❑ Leaked❑ Did not open ❑ Did not open ❑ Leaked❑ Repairs/ Materials . Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight❑ psid psid psid Test gauge used:Make/Model � �� SN: ������?� Date Tested for Accuracy: �— —� � Remarks: The above is certified to be true at the time of testing. Firtn Name 1-'�-� ��IY�,,C�t.�n�f�_Firm Address '� b `,c,� '�1 � � S13� Certified Tester(prin� L°�'rl����ertified Tester(signature) Firm Phone#�[v''I��"'(�C� Cert.Tester No.�od�(��3 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