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Prologis Park-LR170111 (3)
IRRIGATION DOMESTICS FIRELINE The following form must he completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeepinb purposes= BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD..�R 1157004© (Customer) MAILING ADDRESS: Ps,.z 7,5u tJ pk&uad �L L��' !/��■ l �e���fp��7� f CONTACT PERSON/PHONE: 4'-r Z,-IryL 9 X LOCATION OF SERVICE: 'L? L5 Its t1n The backtlow prevention assembl; detailed belo" has been tested and maintained as required b) commissionregulations and is cenifted to be operating %ithin acceptable parameters. TYPE OF ASSEMBLY Reduced Pressure Principle Re used Pressure Principle -Detector Double Check Valve-15ouble Check -Detector PressureNacuumBreaker Spill -Resistant Pressure Vacuum Brea)-cr Manufactumr L 6 —4 Model Number �. � � =�► TV/maize 1' Located AV0.*tV Sc-r.I.,�. ra jat7SedaI Number, to 6 Cy -I L -T is the assembly installed in accordan, a with manufacturer recommendations and -or local codes:' ,s Test gauge used: MakeYModel tl" 8 lK qi _ SN: Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Finn Name � 11AI,cFirm Address Pb &A 33'//:3;--7 Certified Tester (prinI)eR(& AItic Certified Tester (signature) Firm Phone# '�q- o l -4774 Cert. Tester No. AS;W hate �/• !? ' TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS •' USE ONLY MANUFACTURER'S REPLACEMENT PARTS Wbite- City Copy Yellow- Customer Cop), Pink- Tesu:r's Copy Reduced Pressure Princi le A ciribly Pressure Vacuum Breaker Double Cheek Valve Assembly Relief Valve Air Inlet L'heklalGe Ist Cheek 2nd Check Held at -psid Heid ataI psid Opened at Opened at Held at Initial Test Closed Tight Closed Tight 4,10 psid psid psid Leaked Leaked Did not open Did not open Leaked Repairs"' - Materials Used Test After Held at psid Fleid at psid Opened at Opened at Held at Repair Closed Tight ClosedTi,ght psid psid psid Test gauge used: MakeYModel tl" 8 lK qi _ SN: Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Finn Name � 11AI,cFirm Address Pb &A 33'//:3;--7 Certified Tester (prinI)eR(& AItic Certified Tester (signature) Firm Phone# '�q- o l -4774 Cert. Tester No. AS;W hate �/• !? ' TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS •' USE ONLY MANUFACTURER'S REPLACEMENT PARTS Wbite- City Copy Yellow- Customer Cop), Pink- Tesu:r's Copy