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2016_1219 ! 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) , � I Z?, �� _ MAILING ADDRESS: �� CONTACT PERSON/P NE: '�t - LOCATION OF SERVICE: The backflow prevention assembly detailed elow 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 ❑Double Check Valve '�ouble Check-Detector �Press eVacuumBreaker �-iSpi11-Resistant Pressure Vacuum Breaker � �� Manufacturer ��` Model Number �� Size�_ Located At �i��r �`Ir�CQ. �� Serial Number C,�Q.�� -[� 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 ��sS Held at�� psid Held at��psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight,�, psid psid psid Leaked❑ Leakedl ' Did not open .�. Did not open '�1 Leaked� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight C' Closed Tight'��J psid psid psid Test gauge used:Make/Model ,`�� ^ ^ �� SN: 1�tJ"C�� Date Tested for Accuracy: t� � Remarks: The above is certified to be true at the time of testing. �� r �n Firm Name�l��/7C5 1'�t� � �6��`.� Firm A ddress v � �� _ ^ �� t `x� Certified Tester(print) l Certified Tester(signature Firm Phone#��1 �/ 'D " l��. Cert.Tester No. b� ate �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 / 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. '�-�� ✓ `✓ � 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 �ouble Check Valve �Double Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker `A' � n Manufacturer VV�s Model Number��_Size Located At �� Cj Serial Number �'C1a!`�� J Is the assembly installed in accordance with manufacturer recommendations andlor local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve lst Check 2nd Check V17S Held at�-� psid Held at�'�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked❑ LeakedC Did not open 'L', Did not open '� LeakedL 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Ciosed Tight f�� Closed Tight'�� psid psid psid Test gauge used:Make/Model �� SN: �� 1�� Date Tested for Accuracy: �� Remarks: The above is certified to be true at the time of testing. ��A��1�(�� VJ Firm Name �v�� Firm Address �- �, _ Certified Tester(print)��C.1/ ��-� Certified Tester(signatur Firm Phone ��`� �� l�� Cert.TesterNo. �-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