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2017_0103 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) • (� p,, MAILINGADDRESS. �C.l" ��Y� �-I/ IV�A��D CONTACT PERSON/P ONE: • q 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 ��7 Double Check Valve �Double Check-Detectar ❑PressureVacuumBreaker ';�Spill-Resistant Pressure Vacuum Breaker 'r ��i Manufacturer �� Model Number��`"t'x Q(��( Size Located At l.J�� t ��'11t �� Serial Number `�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? l, Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check P� Held at��psid Held at� <�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked� Leaked� Did not open ❑ Did not open ❑ LeakedC I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight 1� psid psid psid Test gauge used:Make/Model ��'�'� �5 SN: 1w t'�� Date Tested for Accuracy: ��— t ��o Remarks: The above is certified to be true at the time of testing. �� r FirmName 1� �,{� �j Ul�fl Firm Address � �� G - Certified Tester(print) l� Certified Tester(signatur Firm Phone# � 1,0' Cert.Tester No. �� l�o(� 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) �n,,`�� r_ r^ �^ MAILING ADDRESS: ��`'� �1 • �1 1'� � CONTACT PERSON/PHONE: - 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 ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker � 3�4 „ Manufacturer `"`� Model Number ��1 �'�. Size Located At��T( ��_��. Serial Number ��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 Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check �JJ Held at 1'1 psid Held at�psid Opened at Opened at Held at Initial Test Closed Tig� Closed Tight �^ psid psid psid Leaked❑ Leaked�' Did not open .=� 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 1 psid psid psid ` '"� � a Test gauge used:Make/Model �1/�� l � SN: 1� "�' �'�� Date Tested for Accuracy: �( Remarks: The above is certified to be true at the time of testing. Firm Name , � [1�� F�� Firm Address �X�(Q�� 1/�i� �� . y� � Certified Tester(print) � lt�IliwY Certified Tester(signatur Firm Phone# �t� � � �g� Cert.Tester No.� b� Date � ?J' �, *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