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2016_1213 / / IRRIGATION DOMESTIC FIRELINE J 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) .- MalLlrr�aDD�ss: �� ' �. S� S��iV1 C��PF.U.. �0 CONTACT PERSON/PHONE: LOCATION OF SERVICE: The backflow prevention assembly de 'led belo 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 �Double Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �n�15 Model Number � l��(, �t��K Size �� Located At �1�Y�ls�c� �� �� Serial Number ���1�� — 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 �j� Held at O •Vpsid Held at�•�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked L�� Leaked���� Did not open -���� Did not open '_I Leaked'_l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight�7 ClosedTight� psid psid psid Test gauge used:Make/Model �� SN: IUC�l�O�� Date Tested for Accuracy: �7`' � «D Remarks: The above is certified to be true at the time of testing. FirmName���R•t'i� �J��n Firm Address ��� DQ�•l�(�' .. �' Certified Tester(print) t F�� Certified Tester(signature) Firm Phone# d�� "l� ` �-- Cert.Tester No.���lb�V Date 4�' t t * 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 LD. #0570040 (Customer) � 1 t� � n E� � MAILING ADDRESS: �I � CONTACT PERSON/PHONE: �O� � 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 '�1Reduced Pressure Principle-Detector �oubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker '`1Spi11-Resistant Pressure Vacuum Breaker VY �s W�ml�, Size 3 „ Manufacturer Model Number Located At 1,/�`�, �5�� �� �4��5�►'�Jerial Number �,�� Is the assembly installed in accordance with manufacturcr rccommen�ati�ns and/or local codes? Yis Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air inlet Check Valve 1 st Check 2nd Check ��f Held at�psid Held at�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight`j� psid psid psid Leaked�� Leaked��l 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 "��� �� SN: `�'�� `" � Date Tested for Accuracy: �� � �b —� Remarks: The above is certified to be true at the time of testing. � � Firm Name �C• �1"�i � t � Firm Address � �� ��' � �' Certified Tester(print) ���RY Certified Tester(signature) Firm Phone��J l� —�IK1� Cert.Tester No.����0�� 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