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2017_0104 f IRRIGATIO N DOMESTIC FIRELINE V 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: CONTACT PERSON/PH NE: � LOCATION OF SERVICE: - 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 ❑Reduced Pressure Principle �1Reduced Pressure Principle-Detector �Double Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker I,:Spill-Resistant Pressure Vacuum Breaker Manufacturer � �� Model Number L�/� Size � �� Located At �,1� ��I (`l�1� �� Serial Number�l� � 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�psid Held at�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked�l Leaked❑ Did not open ❑ Did not open ❑ Leaked`._l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model � U11S l ln SN: l� 1' �� Date Tested for Accuracy: � Remarks: The above is certified to be true at the time of testing. � r Firm Name 1�•�� 4j �� Firm Address '� [�� O�.fl ��• Certified Tester(print) l � Y Certified Tester(signature) Firm Phone# ��_1,�' l a-V�- Cert.Tester No.�� L�� Date � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy � IRRIGATION DOMESTIC FIRELINE v 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) ('�, Q MAILING ADDRESS: WS�J l�� Y l�l I�A � A�0 CONTACT PERSON/PHONE: AC LOCATION OF SERVICE: 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 ❑Reduced Pressure Principle '�Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detector �1PressureVacuumBreaker C1Spi11-Resistant Pressure Vacuum Breaker Manufacturer Fi ModelNumber �►/�� Size �� r�' �y(y� Located At V�1't Sf �� "1 �,/l� Serial Number � 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 ►�7,7 Held at�psid Held at7'��' psid Opened at Opened at Held at Initial Test Closed Tight�t Closed Tight� psid psid psid Leaked�� J Leaked��i Did not open '�:� Did not open u Leakedf 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight��l Closed Tight❑ psid psid psid Test gauge used: Make/Model � � � � SN: �W ` ' a'� 1 Date Tested for Accuracy: ��- l ( Remarks: The above is certified to be true at the time of testing. � . Firm Name l vriTJ �� 1JlJ�Firm Address 1 1J � v�� ' - l^ Certified Tester(print) t � Certified Tester(signat e) \ Firm Phone 1� ��' lI`�/- Cert.Tester Na �O� ate � *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy