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2017_0215_RPZ 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) ,/ (� i �� MAILING ADDRESS: �� ,/"`' U�'vvTU''� T��- CONTACT PERSON/PHON : o a..�" — 3 -3 S �3 LOCATION OF SERVICE: cca�v. c.rc�c., �' 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 C�fReduced Pressure Principle I�Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detector �PressureVacuumBreaker ' 1Spi11-Resistant Pressure Vacuum Breaker A �r Manufacturer �� Model Number l.��1 �� Size� Located At �t�� '(�2� �tiv¢�,:5 �i�t�t;c w� Serial Number ��1 � b 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 �� id Held at l�c,q psid Opened at �a � Opened at Held at Initial Test Closed Tight Closed Tight� psid psid psid Leaked❑ 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� Closed Tight❑ psid psid psid � � ��_t { / Test gauge used: Make/Model ��'hl�d" ��S�'� �GV'd2 SN: t �� (o��'`� 1�o Date Tested for Accuracy: � Remarks: The above is certified to be true at the time of testing. Firm Name�J�'W`��'�►wi�Firm A ddress�� /, �� 1 Certified Tester(print) � G��L� Certified Tester(signature) �� ✓�� Firm Phone#�( � ��J�"�� Cert.Tester No. �PGC� ��S 33 Date 1��=�S' �� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-Ciry Copy Yellow-Customer Copy Pink-Tester's�Copy IRRI6ATION DOMESTIC � FIRELINE The following form must be completed far 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) Ma1Ln•rG aDD�ss: 3 -3 /I/� ��,�ov� `fi' � CONTACT PERSON/PHONE: v i�*� � ��H� g! 5.. �- S �'� LOCATION OF SERVICE: �'�✓t� a.!' 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 .�'1Reduced Pressure Principle �7Reduced Pressure Principle-Detector ��DoubleCheckValve .�1Double Check-Detector �.=1PressureVacuumBreaker �L Spill-Resistant Pressure Vacuum Breaker � �i Manufacturer '�'�,S Model Number ��C?C1� ��- Size v� Located At��C!'Jii� \)G.��`�h\�t�ns�soa,•�� Serial Number �S�I�y;�-- 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�°� psid Held at�.3 ps' Opened at �� Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked�� 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 ClosedTight�� ClosedTight'�.J psid psid psid Test gauge used:Make/Model! ��5�'/�}�S'S��`��1 SN:_�' l U�� Date Tested for Accuracy: �V►5 /�(v Remarks: The above is certified to be true at the time of testing. FirmName/IPU�'' ��''E �� bti,1� 'u��Firm Address 1 � aK �� rIH�Uh If( �� (� Certified Tester(print)�� '�^�� Certified Tester(signature) .uti`` �' �� Firm Phone#��lQ ll�� I�� Cert.TesterNoU\�i7�� Date ��-� �5�� * 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