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2017_0316_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 LD. #0570040 (Customer) ,� ��,� � � r �sa�� MAILING ADDRESS: Pr �, , a oa� mt'.�c+N/� l40< CONTACT PERSON/PHONE: h� h � a� LOCATION OF SERVICE: 7/O �4 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 �Zeduced Pressure Principle ❑Reduced Pressure Principle-Detector ❑DoubleCheckValve �lDouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker �-,-, f( Manufacturer bt1 A�I IS Model Number o 09 �►a � 7 Size� Located At /N Qo�( �� f��1/�t' ,�'�� /�Serial Number 68 7�F� n 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 TightC Closed Tight -�l psid psid psid Leaked❑ Leaked❑ Did not open � Did not open ❑ Leaked_7 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight J Closed Tight❑ psid psid psid Test gauge used:Make/Model 1�1 i� � (A�-�S'�' �y,�`� SN: O oZ{ 7/-J� �P Date Tested for Accuracy: - /7' 1 Remarks: ,� r J u B� C�• Nm� �� The above is certified to be true at the time of testing. Firm Name .��p p`t'rQ l� Firm Address_� �3v'r/ �LyJ'rl/d/�'j ��'` �1.�W1 T ?�O� Certified Tester(print) fJ9►'��UO�SCertified Tester(signature) Firm Phone# R �a S�7 3�� Cert.Tester No.Q�00 Date 3—�6 �J� *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