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RPZ_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 I.D. #0570040 (Customer) MAILING ADDRESS: .z-� `. ��4-�^- CONTACT PERSON/PHONE: n�'�( ' �ti• ;�� LOCATION OF SERVICE: 1- c't�;E� �'��`� 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 ❑Double Check-Detector �PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker Manufacturer (.�Ct,��S ModelNumber LC�� Size +��. Located At S�,�;:�p r�-�k= - ��`'7►"t-..-� Serial Number ��.��3 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 lst Check 2nd Check Held at 4 � 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 I 1 Leakedn 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 � c��u ��zc�. "�ks �'� SN: �!�`l�-s `� Date Tested for Accuracy: _1 >� �'� Remarks: The above is certified to be true at the time of testing. � Firm Name �^-�F'<c;�" �� Firm Address �-2-� �, �YL-u-Y � Pl��( =��3-� e� Certified Tester(print) �%. ��%c�- Certified Tester(signaturel �� ._ Firm Phone# ��'�- � �� r�5 �' Cert.Tester No. /S �`�j/ 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 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: �Z,�� l'.J- �� ST C� 'Pff � ��' CONTACT PERSON/PHONE: ��-'�I ��i_ Tl�� LOCATION OF SERVICE: ccl%�--� '�e� -' Cc - � r� 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 ❑Double Check-Detector [IPressureVacuumBreaker ' iSpill-Resistant Pressure Vacuum Breaker f / Manufacturer (�✓�-� S Model Number �%�� Size� � Located At S�/-' rc�c.E- � �� Serial Number y�7 (`f Z 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 1 Held at �� psid Held at �� psid Opened at � 3 Opened at Held at Initial Test Closed Tight'�' Closed Tight �E' psid psid psid Leakedl�l Leaked❑ id 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 �>�/� y� �c�% T�C S�v SN: G i/Y�1't- Date Tested for Accuracy: � G•� Remarks: The above is certified to be true at the time of testing. FirmName ��l�'�--�=� �'r"C- Firm Address �� . �c� ��fc� � l� Certified Tester(print) C�. �//a��---1� £��:��Certified Tester(signatur Firm Phone# C��'� �-��- 1�-��' Cert.Tester No. I 5 �� Date I�� * 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