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2016_1114 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 LD. #0570040 (Customer) / MAILING ADDRESS: ��� � � �a-� �� �-o � 5� a f `� CONTACT PERSON/PHONE• 3e ��L— �f�-3 � LOCATION OF SERVICE: Sc�-w��- 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��R�e uced Pressure Principle CReduced Pressure Principle-Detector ��ouble Check Valve '�Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker A �f „ Manufacturer Yv0.�` � Model Number � � � � � Size � Located At�-� �a�"�r.���-+'��'ra-r�L� Serial Number 3 �-S� 3 S' / Is the assembly installed in accordance with manufacturer recommendations andlor local codes? 'E- s Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check I�$ 2�y' Held at psi Held at psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight a� psid psid psid Leaked�i 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���1,u '�-S�`� �S — S SN: �`f� �' � � � Date Tested for Accuracy: �� "��� Za l� Remarks: � cL SS'� The above is certified to be true at the time of testing. _��' �/�'2 yj-ea-_n ���,�s 'L 3�S (N. �fi-r r;p r J 1ro�'1-i Firm Name��2,��oTe c.-Frle� Firm A ddres���,,�.o� "rc��;-�2,�/�c, `�S c`t o —� �- � i; , Certified Tester(print) /f�c ,� ��y►�.,p(�.� Certified Tester(signature) G � Firm Phone# ����3�'�S'�v Z-- Cert.Tester No�p c C t Z�� � Date �l� ����"l� * 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) Ma�LnvG ADD�ss: �-�t� -s; h�o �L..� Co ��[ '1 �"'Q l 9 CONTACT PERSON/PHONE: -�c�� �7� �32 -� g LOCATION OF SERVICE: Sc�w•�- 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 `: iR�ed ed Pressure Principle-Detector I 1 Double Check Valve I-�ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker ` �i Manufacturer V et � S Model Number � d � Size $ Located At vEt-v `�- �i� d�r'i�'2--e-v�#-r�C�-Serial Number l/S�'/ Z-� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? V'�s' Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at2 ��psid Held at`r � psid Opened at Opened at Held at Initial Test Closed Tight Closed Tight psid psid psid Leaked' 1 Leaked��l Did not open �� Did not open :7 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 !��d Gv(�Sf ���5'''� SN: �f 6 a.3 � � Date Tested for Accuracy: �a �«— Z� l 6 Remarks: � S Seaj � The above is certified to be true at the time of testing. w e. S f�-v► S.�'�y-�S 2 � � S�' �. �ar r;p,� Tr�.,�L FirmName�ir��r�.��L�, N�Firm Address�a�� Pr�r; ��T�, ?S'Q'�-O � —'�' ,_—,� Certified Tester(print) �l-c, 5 /enti}��;J Certified Tester(signature Firm Phone#���"- 6��i -'�s�v � Cert.Tester No�Pe c!Z� �� Date Cl-� `f -Z e l�� * 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