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2016_1221 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) - '" � �-1 � , Q�� MAILING ADDRESS: OD�V � � CONTACT PERSON/PHONE: � � LOCATION OF SERVICE: The backflow prevention assembly detailed bel w has been tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ;1Reduced Pressure Principle �:�Reduced Pressure Principle-Detector CiDoubleCheckValve �Double Check-Detector �PressureVacuumBreaker �lSpill-Resistant Pressure Vacuum Breaker Manufacturer ��r7 Model Number �� '�t� Size ��1 Located At � ^��.� I��JIM Serial Number �F ��'� 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.l' 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 i 1 Closed Tight�-1 psid psid psid Test gauge used: Make/Model �I`��L�� SN: l� 'O�I Date Tested for Accuracy: �� l ��i -� Remarks: The above is certified to be true at the time of testing. FirmName r��j ��rL 4i �V�D Firm Address t�� G� 1 Certified Tester(print) ' � ��-Y Certified Tester(signature Firm Phone#l�'��0 '-l��- Cert.Tester No. �� Date l � ki *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 F COPPELL PWS I.D. # 0570040 (Customer) -� � , MAILING ADDRESS: d��v�^�(Y U N �� {��V��`( CONTACT PERSON/PHONE: {.l� ' 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 rReduced Pressure Principle-Detector `�Double Check Valve f-i Double Check-Detector �IPressureVacuumBreaker rJSpill-Resistant Pressure Vacuum Breaker 3 ►► Manufacturer rfj` Model Number �� '�j Size Located At Serial Number ��.�o 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�lC Closed Tight � psid psid psid Leakedf-I Leaked'�1 Did not open �� Did not open '�_ I Leaked�-1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight.�7 ClosedTight`.I psid psid psid Test gauge used: Make/Model V��-tl� t� SN: ��1 '��' Date Tested for Accuracy: « < «p Remarks: The above is certified to be true at the time of testing. c r `1 FirmName C��j \t� �li �(Jp.ld,� Firm Address � 1/I�;(,�Q� �� . c Certified Tester(print) I - Certified Tester(signatur Firm Phone# a-��- 3�a- a�a�- Cert.Tester No. 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