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2017_0210_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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: �- ' � CCi �� CONTACT PERSON/PHONE: — — I� � - Z I LOCATION OF SERVICE: 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 �educed Pressure Principle �Reduced Pressure Principle-Detector ❑Double Check Valve �Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �/GL��..7 Model Number L�`Q��f�`�Q'� Size 3�_ Located At /n�r�. rc��j7'►'� 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 1 st Check 2nd Check Held at �-� psid Held at�psid Opened at�� Opened at Held at Initial Test Closed Tightf�, Closed Tight � psid � psid psid Leakedi�l Leaked:�I Did not open I ` Did not open C� LeakedL] Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight C Closed Tight❑ psid psid psid Test gauge used:Make/Model�G?/'%��a�GC� �G1 SN:��y Date Tested for Accuracy: 6��f��/ Remarks: The above is certified to be true at the rime of testing. FirmNamerd��(�G� � �,�/1`.r/ Firm Address�U�'��3� riv�rrT��U�� i Certified Tester(print) �� Certified Tester(signature) . Firm Phone# ��,rp 7�� J'j� Cert.Tester No.��'(J�j)�j 7�� 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 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: - / / CONTACT PERSON/PHONE: LOCATION OF SERVICE: � 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 I�Reduced Pressure Principle �IReduced Pressure Principle-Detector �Double Check Valve �Double Check-Detector ❑PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker �nl�.�� Q�J�� Size�/ �— Manufacturer Model Number Located At �'}')ECy�� r(Il,►�}'Y� Serial Number , � � 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 �� psid Opened at� � Opened at Held at Initial Test Closed Tight�� Closed Tight C� psid psid psid Leaked�� Leaked'��' Did not open '_1 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 n psid psid psid Test gauge used:Make/Model �T%�i� � '�PJL� ,SG� SN: �')��/11 �J� Date Tested for Accuracy: �,?�-1 7�/ Remarks: The above is certified to be true at the time of testing. Firm Name �j�/�CCUl�,�C-G1 �',�,��Gti,s Firm A ddress_�/��c��T�JC,C)�'?��,1,/�yC' ��I / r /�_/ Certified Tester(print)�/1��,/� Certified Tester(signature) �� Firm Phone# �7�C��.,�'7(p Cert.Tester No%/`(�(1��7�� Datez� �� / *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