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2016_1206 IRRIGATIOfV DOMESTIC FIRELIIVE� 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: �ACKF'LO�V�'12E��I�1'I'I�I�i ASS�1'�I�I,�''rES'�'Al�I3 I�I�II���Pdl�I�dC��P�Ii'Y' NAME OF PWS: CI lY OF COPPELL PWS I.D. #0570Q40 (Customer) _ G,�' MAILING ADDRESS: � � � �N�✓ w�7• CONTACT PERSON/PHON : v�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 ❑Reduced Pressure Principle-Detector '�ouble Check Valve ❑Bouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum�reaker Manufacturer � Model Number �C Size 3 " Located At `,l l'( P�'[����Ci Serial Number L�ZZ� Is the assembly installed in accordance with manufacturer recoirunendations 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 +T"!7 Held at �-b psid Held at t•� psid Opened at Opened at Held at Initial Test Closed Tighti� 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❑ psid psid psid Test gauge used: Make/Model � �I-�.S �� SN: �,w l t`�'�{�' Date Tested for Accuracy: �,� 0 Remarks: The above is certified to be true at the time of testing. _�� FirmName �. �� 'S �U�i�D Firm Address �0�51 �ROG�cato� .��'�C, �---� Certified Tester(print) lE�(� ,��Z.'( Certified Tester(signature) 12 v Firm Phone# ���/ J��- �.��- Cert.Tester No.����.AO Date �2 � �6 *TEST RECORDS MUST BE KEPT FOR AT LEAST THRF�,yEARS **USE ONLY MANUFACTURER'S REPLACEME�;i PARTS White-City Copy Y�iiow-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: `�- �3 � �� �- CONTACT PERSON/P ONE: Ac(, � 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 �Double Check Valve ;'�bouble Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker �+ r Manufacturer Model Number D�V� Size�_ Located At �.�lT( P I r �� Serial Number �q o(v f 35 Is the assembly installed in accordance with manufacturer recommendations and/or local codes?�lY S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check �js Held at�psid Held at a'-J psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight.� psid psid psid Leakedf 1 Leaked�� Did not open - Did not open � Leaked'� Repairs/ Materials /� Used ��"�Qri!/ � � � P�'� Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I�� Closed Tight�� psid psid psid Test gauge used:Make/Model �/`� Lt �. SN: �� l �� Date Tested for Accuracy: «- � �b Remarks: The above is certified to be true at the time of testing. FirmName 11�`��t✓ � ��µ� Firm Address ��`J� 1�QJ � �(x • �� Certified Tester(print) �1�,(,/ ��.�� Certified Tester(signature) Firm Phone# lN� ��- t�� Cert.TesterNo. �JP��D�� Date �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