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2016_1216 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 ASSENIBLY TEST ANll MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 " (Customer) MAILING ADDRESS: t�-C�'��,�� '�� ,. ' `c�-t �hk�;�� .� , <<• ��. � --r�:�r,� CONTACT PERSONlPI�ONE:_ C��t F c?,..`��;,�,� . � j,:��,- �-�� E LOCATION OF SERVICE: i�l'k�^l r,F ` ' The bacl�low 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 AS.SEMBLY . ❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector ` - �Double Check Valve ' ❑Double Check-Detector = ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker i Manufacturer �i'��C( Model Number �� (f�^E � Size �/� � n Located At �, �T`( �C F �(E�;5;,� �"�� Serial Number t L� �Ck�.F Is the assembly installed in accordance with manufacturer recommendations and/or local codes?_ �t'ci Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve lst Check 2nd Check � a ��5 Held at�psid Held at k• i psid Opened at Opened ai Held at Initial Test Closed Tighfi� Closed Tight�Q psid psid psid Leaked0 Leaked❑ id not open Q Did not open ❑ Leaked❑ Repairs/ - Materials Used ..; Held at psid Held at psid _i Test After Opened at Opened at Held at Repair Closed Tight� Closed Tight❑ sid � P psid psid � _ �; Test gauge used:Make/Model �1� ��f� � �,� SN: ��v"�� :� Date Tested for Accuracy: �� t �f t., � '' Remarks: � -' .; �.� The above is certified to be true at the time of testing. ; �.� ; ,. F. ' � 4 2 �, ;; Firm Name_�Y��`.4 �"`.�Z-� f �\�`.i�°�� Firm Address k�`�� i��.��.,u��%� i�:-'�� :`�.�� `j'�- ,1 ----� �`, i � - �.;.�` Certified Tester(print) �.�€�'�,�;r.r. ��,;'Z.i2'( Certified Tester(signahzre)��,.��:/'?�T ' � � � �\ � % i 't% � -i F� � ��'r` l� �',,�. Firm Phone#i c�`-i r��?' ��j� Cert.Tester No.`��C`�"rt tE.-,,F, 'Date �� E :�., �!(� - *TEST RECORDS MUST BE KEpT FOR AT LEAST THREE YEARS � t **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 ASSEMSLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) � _ 1 �" i �1 MAILING ADDRESS: � �'�"�"��',t�'',«;�; � � r :h��.��,�.'TE,( ��e1(.�tZ��,� t E�, . � CONTACT PERSON/PHONE: �fi�i_',� i'`�i�-�i�'�,nE�-2 f�°�,-t�t� '_��.-.- �F�f LOCATION OFSERVICE: f.`�''�-��'�h�=. i � � � -. � 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 ❑Double Check Valve l�ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker � � ,� Manufacturer �� Model Number f� Size ^ !'� r-� _ [ f ,� ' Located At `. �T`� `t�<< p:�i,1;� �L_ Serial Number �`� ��'4'��r� � Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �f C� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check � ��t�� Held at �?•�' psid Held at�psid Opened at Opened at Held at � Initial Test Closed Tight�f Closed Tight � psid psid psid = Leaked❑ Leaked❑ Did not open 0 Did not open ❑ Leaked0 Repairs/ Materials Used Held at psid Held at psid Test Ai�er Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model �'�f��t�.5 c �j SN: t`�'�� ^�� Date Tested for Accuracy: t�-F�f�, � � Remarks: - The above is certified to be true at the time of testing. �� r {� FirmName ��?��`Lt__ `� ��`.�^`�� Firm Address �n��'� \1��!��',t�� ,%��.�J ��(--� �)',`- ' � r .r--�- • �l � � {- S'' f^,lt. s�'� i ° ,/ Certified Tester(print) / 4� '�(' Certified Tester(signature��...- �yt.�-:. i ` 1 i ,/� � �� 1 �7- � � ��` r 1^�,1"` �;, � f �✓� �`► Fum Phone# ��•� l�� ` �� c�. Cert.Tester No.�L•� ��f�s—�Date ��--- �� t� ' f *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