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2016_1219 (2) IRRIGATION � DOMESTIC FIRELfNE � 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� �r'o�� f� i � �I CONTACT PERSON/PHONE: a+�i S . u c� �Z I`f— G. - 6 D LOCATION OF SERVICE: �}l�0 �✓I ocI«'r^� h1 �/� 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 ��iR duced Pressure Principle -1Redticed Pressure Principle-Detector ouble Check Valve Double Check-Detector I IPressurcVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker c � r� Manufacturer ��C.O Model Number 0 S � Size z Located At rroc'1� O�r ��-�1Gbl i ot �Q1��¢" Serial Number �'t �5�� 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 o29 psid Held at �v� psid Opened at � Opened at Held at �rial Test Closed Tight��t Closed Tight �� psid psid psid al.JLj Leaked' I Leakedl � Did not open ! Did not open I Leaked � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight! � Closed Tight I psid psid psid Test gauge used: Make/Model l�(►�IbraC-c� "�D�-'2'Op �i� SN: �--�gOC� Date Tested for Accuracy: ��' %� Remarks: The above is certified to be true at the time of testing. Firm Name li0 p��, '�S� Firm Address /�3 w� '�' ��r � e`� [� � iI � � � Certitied Tester(pr:nt) L,JcaC?Id 0�1 l Certi�ed Tester(signature) Firm Phone# ��l�79(O ��Q Cert.Tester No. �(o� Date �� * 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 � FIRELlNE � 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) �1 MAILING ADDRESS: f 0� ' � L-o �� X CONTACTPERSON/PHONE: ia5 ! -� ' `��' LOCATION OF SERVICE: i' The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable paraineters. TYPE OF ASSEMBLY : IReduced Pressure Principle '.-1Reduced Pressure Principle-Detector � IDoubleCheckValve ' ;Double Check-Detector �IPressure;VacuumBreaker !Spill-Resistant Pressure Vacuum Breaker � �i Manufacturer �a�✓� Model Number ��J � Z Size � � Located At �� /"��LL Serial Number A��o �3Z Is the assembly installed in accordance with tnanufacturer recommendations and/or local codes? �.' Reduced Pressure Princi le Assembl Pressure Vacuum Breake�- � Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check ��j� Held at 7�6 psid Held at psid Opened at 3�� Opened at Held at Initial Test Closed Tightl I Closed Tight I 1 psid psid psid Leal<edl I Leaked' I Did not open I Did not open ! Leaked ! 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 �� 1'� SN: z�� Date Tested for Accuracy: 9 �� Remarks: The above is certified to be true at the time of testing. Firm Name �'6 l -L J� Firm Address �� `Ll 'l (�-�� `�I ` �' � Certif7ed Tester(pr;nt)�q�j/�� l�i� Certified Tester(signature) G� � , � Firm Phone# ��' `� /� ��T d Cert.Tester No. 1 �OQ � Date / �� * 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