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2017_0110 / 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: �IA � `� u � � • 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 7Reduced Pressure Principle-Detector '�oubleCheckValve f�Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker \A( ic Manufacturer V V��S Model Number �O�ilh� Size � Located At ��-c�c ��T t�. �/f�l�� Serial Number 7iq� �( Is the assembly installed in accordance with manufacturer recommendations and/or local codes? l�is Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check ��L� Held at psid Held at psid Opened at Opened at Held at Initial Test Closed Tight'��i Closed Tight ��I psid psid psid Leaked I�'� Leaked❑ Did not open _1 Did not open ! ; LeakedL i Repairs/ ��1 (.�i � (�� _�� .1�.� � �SS�}�.(�'� � � � � Materials Used "�T CoG�S�3 �� . CAr11Q�"EI,'f 4 t�l�-i"� � Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight f� psid psid psid Test gauge used:Make/Model i L(1� � SN: ��0 1- �� Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. r �r Firm Name � � �JV�'� Firm A ddress �� fl }C- � �Gn,, — Certified Tester(print) l^ G-�-�K�Y Certified Tester(signatur Firm Phone �ti �— Cert.Tester No.�cJ�� t�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 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) �(�'�� (�� MAILING ADDRESS: � < < I �V1I CONTACT PERSON/PHONE: '� 4 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-Detecfnr- ❑Double Check Valve �ouble Check-Detector ❑PressureVacuumBreaker [_]Spill-Resistant Pressure Vacuum Breaker Manufacturer �s Model Number Vl�� ,� i Size u Located At � ` �I v �j�� 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 L Held at psid Held at psid Opened at Opened at Held at Initial Test Closed Tight��7 Closed Tight ❑ psid psid psid Leaked❑ Leaked'�-' Did not open � Did not open � Leaked❑ Mate ials �� / �` M� �' ��'` '� �� J �� 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 Y�� ` SN: ��0—1��I Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. � r Firm Name_�� µ� Firm Address �� 0�� (, . . �� Certified Tester(print) l� � Certified Tester(signatur Firm Phone#��7� " 1.�� Cert.TesterNo. Qwt/l � Date i �o � * 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