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2016_1219 ---- IRRIGATION�_ DOMESTIC FIRELWE � The following form must be completed for each assembiy 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) 1� e�1 MAILING ADDRESS: � �3 ��'aY� Pj' �✓• CONTACT PERSON/PHONE: ac�', ctc%ra �Zl — g� --�D�� LOCATION OF SERVICE: 300 dl'� �r n� The backflow prevention assembly detailed below as been tested and maintained as required by coinmission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY IReduced Pressure Principle :iRed�iced Pressure Principle-Detector �y�ouble Check Valve 'Double Check-Detector �IPressur�VacuumBreaker �Spill-Resistant Pressure Vacuum Breaker �p /� Manufacturer rebG O Model Number �� Size�_ Located At �rOnt �jT S�O� J -C� Serial Number �d� �� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker � Double Check Valve AssemUly Relief Valve Air lnlet Check Valve 1 st Check 2nd Checic Held at�r7 psid Held at 2��psid Opened at Opened at Held at ' 'al Test Closed Tight� Closed Tight � psid psid psid as�j Leal<edl I Leakedl I Did not open I Did i�ot open : Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Ciosed Tight' i Closed Tight' I psid psid psid Test gauge used: Make/Model �11'►�CD ��'"�-d� `�{ SN: i�5�� Date Tested for Accuracy: � /��v Remarks: The above is certified to be true at the time of testing. Fir�n N ame C�,o e l� -a-S� Firm A ddress � `�-I�I' � C�/l � Certitied Tester(pr�nt) �' �l Certified Tester(signature) \ Finn Phone#��7 ` � � `��7� Cert.Tester No.O/�Q�� Date �� g ��o * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT 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 recordlceeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: I C)3 � C'i�" � -�� CONTACT PERSON/PHONE: �ia5 �-� -`l �a -`c'30 0 LOCATION OF SERVICE: (Yl � � �.ane The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable para�neters. TYPE OF ASSEMBLY : iReduced Pressure Principle '.-1Red�iced Pressure Principle-Detector 1�DoubleCheck Valve ' ':Double Check-Detector flpressurcVacuwnBreaker 'Spill-Resistant Pressure Vacuum Breaker � i� �l/ Manufacturer ITepG� Model Number �5� Size Located At ��1� �� a�' � �"' C� Serial Number�o��d Is the assembly installed in accardance with manufacturer recommendations and/or local codes? es 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 Z�� psid Opened at Opened at Held at I ' �al Test Closed Tight� I Closed Tight � I psid psid psid �rj Leaked l I Leaked! i Did not open i Did not open ! Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight' I ClosedTight I psid psid psid Test gauge used: Make/Model �� `�-� "��+ aa� �k SN: �'S db�d Date Tested for Accuracy: �f/� �� Remarks: The above is certified to be true at the time of testing. Firm Name�pD��` ��-� Firm Address ��0� �I`�i1 �i' `►r. � �// � Certified Tester(pr�nt)�QUf' �.,r�Certified Tester(signature) ~ Firm Phone# ��7 "�� '��"l� Cert.Tester No �OQlo7�8 Date f�"�g'Ib * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy