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2016_1220 IRRIGATION DOMESTIC C FIRELINE � 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) MAILING ADDRESS: (303 W�an5l�r ti r �(�(���� CONTACT PERSON/PHONE: Leu�s S z�`��`�`�b�+�''d`� LOCATION OF SERVICE: I ( '� SaMur. S (�Iv c� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within accepeable paraineters. TYPE OF ASSEMBLY ` iReduced Pressure Principle '-]Reduced Pressure Principle-Detector y4'Double Check Valve : !Double Check-Detector ' IPressur�VacuumBreaker !Spill-Resistant Pressure Vacuum Breaker c/ 2'` Manufacturer �eh�o Model Number b b5 � Size --�'-1�tSZ Located At �T'��'}' e'� �- SG�'`�'�� Serial Number l � Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �S � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air lnlet Check Valve 1 st Check 2nd Checic Held at�, '..�psid Held at� , � psid Opened at Opened at Held at �'tial Test Closed Tight �V Closed Tight � psid psid PS�� a55 Leakedl I Leaked' I Did not open I Did not open ' Leaked � Repai rs/ Materials Used Test After Held at psid Held at psid Opened at Opened at Held at Repair Closed Tight' I Closed Tight' I ps�d psid psid Test gauge used: Make/Model ��Ih���-� '��'" ��� SN: Z5�Sa�� Date Tested for Accuracy: � I�b (�° Remarks: The above is certified to be true at the time of testing. Firm Name �PP z'1 �S� Firm Address �3�3 � �er `--i,� � � � Certitied Tester(prnt)�V�E�1�� ��1 Certified Tester(signature) Firm Phone# 2��—��� '��4� Cert.Tester No.1-� ��7�� Date jZ Zd���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 /�I� 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) /J � f> MAILING ADDRESS: 1 �O � l.�l� t1l'l t►� l� �✓� �� CONTACT PERSON/PHONE: ' E.G' � �r " 9 � l��K' LOCATION OF SERVICE: //3 �/✓!G<��5 ��1�'cI 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 �bouble Check Valve ' !Double Check-Detector I IPressureVacuumBreaker ',Spill-Resistant Pressure Vacuum Breaker �1 /� Manufacturer / `',JLd Model Number � � Size�_ Located At I-f�0 n'� p� S�a � Serial Number tT �J?�P�� 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 Check Held at Zrr'1 psid Held at�psid Opened at Opened at Held at �tial Test Closed Tight� i Closed Tight I I psid psid �sid �-�jtj Leakedl I Leakedl I Did not open i Did not open I Leaked � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight' I ClosedTight ! psid psid psid Test gauge used: Make/Model �J�M�fl'tC� �'-�-�t�� SN: .�S�Ur� Date Tested for Accuracy: �//� ���o Remarks: The above is certified to be true at the time of testing. Finn Name l..d !� `L�� Firm Address �3�-3 �^'� �� �r ` y� �/ ^ � Certitied Tester(pr;nr) v�'^ �� ` Certified Tester(signature) Firm Phone#�� (- l ��� g� l� Cert.Tester No��r/�Vb751� 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