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RPZ_2017_0117 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) L MAILING ADDRESS: I?J S S lz.P/�7dV1 �Cc CONTACT PERSON/PHONE: C — — LOCATION OF SERVICE: Cc 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 JReduced Pressure Principle-Detector �J ouble Check Valve �Double Check-Detector 'PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker � �, !/ Manufacturer �a- 5 Model Number QOq � Size �2 Located At ��'� �'�✓�� Serial Number 3?3 S 3 8 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 Held at ��Spsid Held at ��psid Opened at �� Opened at Held at Initial Test Closed Tight�' Closed Tight� 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� I Closed Tight� � psid psid psid Test gauge used: Make/Model �'1-�Gtit S �r� SN: d 30 g0 �(� 2 Date Tested for Accuracy: �—� S'l� Remarks: The above is certified to be true at the time of testing. FirmName � rJ �� Firm Address �� Z�0/lr f !' o'r�Q,/'�r/U�� 7So27 f� � � Certified Tester(pr�nt) �ll(,Q� G�G�'�� Certified Tester(signature) ' Firm Phone# Z��",�U2— 7lOQ Cert.Tester No._ ��00/Z7ZO Date `� �7�� * 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 recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) — l MAILING ADDRESS: 13 S S �iWl eVl T`t CONTACT PERSON/PHONE: 2— Z � LOCATION OF SERVICE: The backflow prevention assembly detailed below has been tested nd maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY educed Pressure Principle ;Reduced Pressure Principle-Detector � ouble Check Valve -1 Double Check-Detector '-PressureVacuumBreaker ,Spill-Resistant Pressure Vacuum Breaker �/�/� Model Number � !� Manufacturer �0�� Size �Z Located At �� rdOM C��a'-I�V Serial Number 37Z 9 93 Is the assembly installed in ccordance 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 Held at /' / psid Held at �`'�psid Opened at �'s Opened at Held at Initial Test Closed Tight� Closed Tight� psid � psid psid Leaked�� Leaked. 1 Did not open Did not open '� '�� Leaked� I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Hcld at Repair Closed Tight 1 Closed Tight psid psid psid Test gauge used: Make/Model w' L�S �r SN: ��Z- Date Tested for Accuracy: �'^��e Remarks: The above is certified to be true at the time of tesring. FirmName �� U�-F.f�� Firm Address Yd �"J✓�2"7��5 /��'Wl�"r�./�i1��7�(Z'� c � Certified Tester(print) �IrULQ__. ��/n Certified Tester(signature)�_ , � Firm Phone# 2�'SO'Z.��]�pU Cert.Tester No. 1J�d��^7� Date � '1��`� * 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