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2016_1209 f 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: �V�l� CONTACT PERSON/PHONE: 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 f�Reduced Pressure Principle [�1Reduced Pressure Principle-Detector ❑Double Check Valve 3�ouble Check-Detector ❑PressureVacuumBreaker I-1Spill-Resistant Pressure Vacuum Breaker �'f��JF�L��4 �C/� Size u Manufacturer Model Number Located At l�l� ` �� i'��- C r/l.� Serial Number L�� l� �/ Is the assembly installed in accordance with manufacturer recommendations and/or local codes? lGs 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'' ': Leaked.- Did not open .I Did not open , l LeakedC-1 Repairs/ Materials Used 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 VV� � ^ �� SN: `� l"v'C"� Date Tested for Accuracy: ��" Remarks: The above is certified to be true at the time of testing. ^ r , � � FirmName �•��'fj WV�� Firm Address �� . �^ Certified Tester(print) l Certified Tester(signature Firm Phone# � ��' �� Cert.Tester No. ��D� Date � l�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/P ONE: t� ' 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 �poubleCheckValve f�Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �J�GY �C� Model Number �� Size 3 .� Located At �� t'�� Serial Number q D��-F3 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 �7 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 ', 1 Leaked!1 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 �►v «/�'� �� SN: �C� 1��`L+�� Date Tested for Accuracy: « � �� Remarks: The above is certified to be true at the time of testing. Firm Name�-� % �j WV� Firm Address t0�'�J� l.�w� � ��'��• _ �. Certified Tester(print) l Certified Tester(signature) Firm Phone# �� `� 7- Cert.Tester No.�-1b� 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