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2016_1220 IRRIGATION DOMESTIC X 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: I U 3 � ev e�� CONTACT PERSON/PHONE: l.-ou�s eic,S �-1`}-4S1.•��46 LOCATION OF SERVICE: ��' �• 17�r►'�on '�aP• 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 �Reduced Pressure Principle '-!Red�iced Pressure Principle-Detector �Double Check Valve !Double Check-Detector ' I Pressure Vacuum Breaker -�Spill-Resistant Pressure Vacuum Breaker Manufacturer � Wa 1-` Model Number �'�11� � Q� Size Z�� Located At �p�� J i de G`�' P+'ti�e�-1 Serial Number � �� 3� 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 Inlet Check Valve 1 st Check 2nd Check Held at�psid Held at Ci psid Opened at Opened at Held at I itial Test Closed Tight i Closed Tight 114 psid psid psid �p��j J' Leakedi 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 Closed Tight' � Closed Tight I psid psid psid Test gauge used: Make/Model l_.t��►b��v `f�" Z c�� f►L SN: Z s�b D d Date Tested for Accuracy: �/«�� Remarks: The above is certified to be true at the time of testing. Firm Name D�'�I � S� Firm Address � 3d� �� 1� �� /l � � Certified Tester(pr;nt) U i�� Certified Tester(signature) � � Firm Phone# Z��-`C /� � ��`rd Cert.Tester No..CS�DD��o75� Date ��" 2D /�' * 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 FIRELWE � 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: �3C�� l.�rc�►'Lo,IC►' �ir� l�vP�� CONTACT PERSON/PHONE: 1-ou�S f►'�ac I'as z 14-�{Ct tp-��k� LOCATION OF SERVICE: `71�G � � v�-�o� `'�a,Q 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 '.-1Red.iced Pressure Principle-Detector )C!'Double Check Va1ve !Double Check-Detector '1 Pressure Vacuum Breaker �Spil1-Resistant Pressure Vacuum Breaker Manufacturer ��Lc� ModelNumber �(SSrG Size Z � Located At Iv ort� S�r�e p F �Jld c� Serial Numbel• N D��9� 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 Inlet Check Valve 1 st Check 2nd Check Held at Z,I psid Held at �� psid Opened at Opened at Held at I tal Test Closed Tight'� i Closed Tight �1 psid psid psid �Gs�j Leakedl I Leakedl 1 Did not open � Did not open ' Leaked i Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' I Closed Tight I psid psid psid Testgaugeused: Make/Model�rv�l�t�et3 `CO" Z�� « SN: Z��vOL''� Date Tested for Accuracy: �71�a I 1 b Remarks: The above is certified to be true at the time of testing. Firm Name��.�-t� -4-51� Firm Address �C�� f.� !'E'1 � �-t;►'� � e�� \ � 9 � Certified Tester(pr;nr) �O�C9 t� ��y Certified Tester(signature) Firm Phone# ��'4��`f� Cert.Tester No.�T��s� Date f Z z��(° * 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