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2016_1220 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 recordl<eeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) 1 n !) �'1 MAILING ADDRESS: �vo 3 l��n I�r" l,�r. �o CONTACT PERSON/PHONE: � �'ct, LOCATION OF SERVICE: S ca Z 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 IReduced Pressure Principle _iRed�iced Pressure Principle-Detector �Double Check Valve 'Double Check-Detector 1PressurcVacuumBrealcer -�Spill-Resistant Pressure Vacuum Breaker c�.. �^ ,r Manufacturer�Cr'�CO Model Number u � � Size Z Located At �'nb� o-� �JC-�o' �'�'K- Serial Nuinber �f /��7 ! 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 ��5 psid Held at Z► psid Opened at Opened at Held at [n ial Test Closed Tight�� Closed Tight V�I psid psid psid �n�j5 Leakedl I Leaked! t 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 CiosedTight I psid psid psid Test gauge used: Make/Model �Mb�cv `f0 °- �� << SN: ��an� Date Tested for Accuracy: ��jb/ �6 Remarks: The above is certified to be true at the time of testing. Firm Name��fl --✓�S� Firm Address I�� ler �� l� '�l�� r 7 Certitied Tester(prinr)�av ic� �i�H� Certified Tester(signature) � , Firm Phone# �/T � 'T ��- ��`� Cert.Tester No.��d1a75� Date �� 2�%'�' * 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) i �J n MAILING ADDRESS: 1303 v�ra ler l�ir l.O ei� CONTACT PERSON/PHONE: Lo�it c.�'a LOCATION OF SERVICE: ( 'L A 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 IReduced Pressure Principle '-iRed�iced Pressure Principle-Detector ;�4DoubleCheckValve .Double Check-Detector i 1 Pressur�Vacuum Breaker -i Spill-Resistant Pressure Vacuum Breaker i� Manufacturer �e�DC.0 Model Number �s� Size � Located At /�r'on� o� �C�EDI ��C`'C Serial Number /'� �d�Q� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e 5 Reduced Pressure Princi le Assembl Pressure Vacuum Breaker � Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at Z�c psid Held at ��psid Opened at Opened at Held at I al Test Closed Tight'i'� Closed Tight �'1' psid psid psid �cL`'j5 Leaked! 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 Re�air ClosedTight� i ClosedTight i I psid psid psid Test gauge used: Make/Model �fi��-U �0`- Z� '� SN: �$�b0 Date Tested for Accuracy: � �� Remarks: The above is certi�ed to be true at the time of testing. FirmName L:.DQpe�� S� �,�t�� n I� �t(^ Firm Address � Certitied Testcr(pranr)pQV��t '�j Certified Tester(signature) � ' Firm Phone# Z��T �9�'"`�D� Cert.Tester No. f�DD 7�JS Date�a � �� * 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