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RPZ_2016_1219 IRRIGATION DOMESTIC v FIRELlNE � 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) � /1 �� ( x, MAILING ADDRESS: 13p� i�r� �r' ',�- : ��o CONTACT PERSON/PHONE: `s' C t' S Z/ —��t� — O LOCATION OF SERVICE: D �- C� �� - N�=. The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable paraineters. TYPE OF ASSEMBLY �educed Pressure Principle ":�Reduced Pressure Principle-Detector ; IDoubleCheckValve i 'Double Check-Detector ; IPressur�VacuumBreaker ;Spill-Resistant Pressure Vacuum Breaker /- , j �i Manufacturer WQ7�s Model Number 9�� Size � �•7- Located At c.o�0 /�'A�-C- Serial Number `7J��J � I Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e 5 � 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 .2�� Opened at Held at Initial Test Closed Tightf i Closed Tight I 1 psid psid psid as�'j Leakedl I Leakedl � Did not open i Did not open ! Leaked i 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 l.F) bro-LO �Q -� Q��i� SN: �i� ��L�U Date Tested for Accuracy: � /`o Remarks: The above is certified to be true at the time of testing. Firm Name ��Pel I -�- s� Firm Address 1�� Y �i� . �D / � � CertifiedTester rnr �U1�CI L�Q r�l ' (p � ) � Certified Tester(signature) Firm Phone# �� I b ��7� Cert.Tester No.��0 Date �� l9 * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC � FIRELfNE � 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) n �i� .�� MAILING ADDRESS: � ►`� ✓� �� CONTACT PERSON/PHONE: -! LOCATION OF SERVICE: OD '�`n �� 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 -1Red�iced Pressure Principle-Detector � IDoubleCheckValve ",Double Checic-Detector i IPressurcVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker ,�/� !� Manufacturer W Cl7't� Model Number L� 0�_I 1► t� Size �� Located At 1'� � �c�� Serial Number ��3$�`'b Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �� Reduced Press�ire 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 �D Opened at Held at Ini ' I Test Closed Tightf i Closed Tight i I psid psid psid ��j5 Leaked l I Leaked' i Did not open '� Did not open ' Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight' ! ClosedTight' I psid psid psid Test gauge used: Make/Model �mb/zt C!� '�0'�-OD �� SN: Z��jQ�Q Date Tested for Accuracy: �1�� /� Remarks: The above is certified to be true at the time of testing. -�" 3a.� l�n� ter �`r. � �-�� FirmName p�e�l `�' �� Firm Address � Certified Tester(pr�nt) � C°i Certified Tester(signature) ` � Firm Phone#f�`f� '7 /� ��/�' Cert.Tester No.�� G Date � �9 �[� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy