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2017_0224_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: L � S � I f = !�j' CONTACT PERSON/PHONE: '�. �' LOCATION OF SERVICE: Yl� � �" � � 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 �Reduced Pressure Principle-Detector ❑DoubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �,�/� �_� Model Number L��'/�}— Size� Located At I�� rJO �✓? �2. I�'�J�� Serial Number � �S �Z �' Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Q 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 atl !O Opened at Held at Initial Test Closed Tight� Closed Tight C�' psid psid psid Leaked❑ Leaked��r Did not open ❑ Did not open �` Leaked�l 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 �� ' �1 '� SN: ("j %J I��C�� Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. FirmName r �� !�[C(fYj�'�t/��iG#�'(J Firm Address 1'� � (p�, 2 � j�c�;�� Certified Tester(print)��V� Certified Tester(signature) � ��'i� Firm Phone#_��q, �7��_Cert.Tester Na r��(��%`j 7�� Date �"�`�-� / * 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 LD. #0570040 (Customer) ��" MAILING ADDRESS: �I G�✓ ' �S� I ' T�G��' CONTACT PERSON/PHONE: f}�� ' P � LOCATION OF SERVICE: . �� 1 Y 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 �Reduced Pressure Principle-Detector ❑DoubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker �!Spill-Resistant Pressure Vacuum Breaker �l �S � Manufacturer �. Model NumberL��fi Size�Z Located At �✓�/'�u �'i��^'l r��^�' �Z- Serial Number ��s�� ? 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 3-� Opened at Held at Initial Test Closed Tight�`�J Closed Tight [� psid psid psid Leaked❑ Leaked�' '� Did not open �'�I Did not open ❑ Leaked-', Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight D Closed Tight� psid psid psid Test gauge used:Make/Model�al,I� yQ"�t�Q ��i( sN: �j/Il�9� Date Tested for Accuracy: -/7-'/7 -G '� Remarks: The above is certified to be true at the time of testing. Firm Name,�( /TC��/}�/ ? �/Q�%,J Firm A ddress � �(,��1��71�1�1 �'��i� Certified Tester(print) ��C�/.7�{� Certified Tester(signature)�� C�� Firm Phone# �7�- l0 �.7/�� Cert.TesterNo�G`�C�j�� Date2'� ��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