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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 recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) /� MAILING ADDRESS: �3�3 l,�ranc, (er �,'r L-D p�r,l '� CONTACT PERSON/PHONE: l-��S Ma.�i as Z�� f�t�-�C��FU LOCATION OF SERVICE: s5� �V i��rtforZ '��,i P The backflow prevention assembly detailed below has been tested and maintained as required by coinmission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY : iReduced Pressure Principle '-'Red�iced Pressure Principle-Detector t�'I�Double Check Va1ve Double Check-Detector I1PressurcVacuumBreaker 'Spill-Resistant Pressure Vacuum Breaker Manufacturer �A`�"�S Model Number 04`7 - m 1 (�1 i Size Z�� Located At �`� • ��'e d`� a�� Serial Number � Z,7��.� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e5 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 � Q psid Opened at Opened at Held at Initial Test Closed Tightl i Closed Tight � I psid psid psid pQ� Leakedl 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 ! CiosedTight I psid psid psid Test gauge used: Make/Model�om hr�iCb �a '�z-�O �Tl� SN: Z��D�� Date Tested for Accuracy: ��lb�l�o Remarks: The above is certified to be true at the ti�ne of testing. /� / Firin Name Lp��I�P�I .�S.D Firm Address �D,j f1�f1 ' �j� � Certified Tester(prPnr)� ( Certified Tester(signature) � ` Firm Phone# ��`�9�0 ��U�� Cert.TesterNo. �JP�O��7Jr"L� Date �� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT PARTS White-City Copy Yeltow-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 recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: I3�� U.�t`c.ir�Q er �� C'�,�Q�i1 �� CONTACT PERSON/PHONE: u i'S ` S 214 ' `�F9� ' G 4� LOCATION OF SERV ICE: ��c� Aj• en or� 'Ta ra 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 '-1Red�iced Pressure Principle-Detector � IDoubleCheckValve ;Double Check-Detector I 1 Pressur�Vacutnn Breaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �!I�I 1�1 11 S Model Number �� /� �7 Size � �Z r Located At I(�p r�� s�� o� �t�r`��r�r'g' Serial Number �� je� � 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 Inlet Check Valve 1 st Check 2nd Check Held at (��f psid Held at�psid Opened at Opened at Held at In al Test Closed Tight!� Closed Tight '� psid psid psid �q,�j Leaked� I Leakedl 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' i Closed Tight ! psid psid psid Test gauge used: Make/Model�mb��-�% �r�� T� SN: Z��DU Date Tested for Accuracy: � /(o�/�v Remarks: The above is certified to be true at the time of testing. Firm Naine��DOe-I( �-�Q Firm Address �� Certified Tester(prinr) D��` � Certified Tester(signature) � Firm Phone# ��T�`C9 L�� Cert.Tester NaEJI �� Date � � f� * 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