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2016_1130 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) MarLnv�a��ss: ��,'3 C:..>� �4, «,S?_ CONTACT PERSON/PHONE: ( c..�i e i5�cl�.t�- LOCATION OF SERVICE: ,� c�c.��c� �C'•�c'� 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 ❑DoubleCheckValve �ouble Check-Detector �JPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer (��..�� Model Number �C�% i�!! Z Size ��`� Located At Y—��e � -�- V��:�-��" Serial Number :�� -�'�'/ I � Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 4�'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 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 ❑ 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 .t�� 2c:t. � TL' j�' SN: C�I�E/�.S �'1� Date Tested for Accuracy: �� :-Z � , Remarks: The above is certified to be true at the time of testing. FirmName �^�-�� ''�� Firm Address �� -t;. /��fty �� 3� , , Certified Tester(print)1;�, ��ti►'�-ti-p ��c.r�%�1 Certified Tester(signature�� _ � ---__ ; — Firm Phone# ��Z '��'� ��Z�v Cert.Tester No.�� Date ��—J�'—�� *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) Ma1LnvG aDDREss: �j �� . i� e�<'��--. CONTACT PERSON/PHONE: LOCATION OF SERVICE: � c�c.�t'cS � � �� 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 C1Reduced Pressure Principle-Detector �oubleCheckValve ❑Double Check-Detector [-IPressureVacuumBreaker ;JSpill-Resistant Pressure Vacuum Breaker c Manufacturer �,,j�,'�� Model Number � �� L-� C f�� Size �� Located At ��•�L ��^i u c:..,��— Serial Number �� L'�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��'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 at �.� psid Held at �,� psid Opened at Opened at Held at Initial Test Closed Tight�' Closed Tight �' psid psid psid Leaked�l Leaked❑ Did not open �l Did not open ❑ Leaked�_� 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 � �� l�� :C� � �k S� SN: C�/l Y�-S`l� Date Tested for Accuracy: ,� �L Remarks: The above is certified to be true at the time of testing. FirmName.�.�-�„(dc�-c�` ��r�- Firm Address 9�1 �' �� 1'c�c� � /.� � � � . '�� Certified Tester(print)C,�. �l��+-.Q ��4%c�� Certified Tester(signature),� -%"�� Firm Phone# �^�� -�.�j� ��-�� Cert.Tester No. �S�5 1 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