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2017_0925 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: I303 �v�u.P1c�IE'�/ �r ��PGI� K CONTACT PERSON/PHONE: L.ok�'S �GruS /z/y- 9�- 8'd`� LOCATION OF SERVICE: 13v I (��a�na�fi- 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 ` iReduced Pressure Principle �.-IRed�iced Pressure Principle-Detector ��Double Check Valve i !Double Check-Detector '; IPressurtVacuumBreaker �iSpill-Resistant Pressure Vacuum Breaker � �i Manufacturer Q� Model Number (��7/I'J / QT Size Located At �a S'� �oM� Serial Number !� �CJ.3� 7 Is the assembly i�lstalled in accordance with manufacturer recommendations and/or local codes? � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Checic Held at 2.�3 psid Held at Z�� psid Opened at Opened at Held at Initial Test Closed TighYh� Closed Tight i�K psid psid psid Leakedl I Leaked� I 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' I ClosedTight� ! psid psid psid Test gauge used: Make/Model �M.�Jro�c.,t� �O�-�� SN: u-�� Date Tested for Accuracy: TI�1 Remarks: The above is certified to be true at the time of testing. Firm Name�� -4- s� Firm Address 3�3 (� �� `r CertifiedTester(pri^t)��!�C, �1�Pr� CertifiedTester(signature) � Firm Phone# Zl�'��v`��"� Cert.Tester No.�POL1��Cp��g Date / Z /7 * 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 recordl<eeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: I 3 O �' i,�- �� -t CONTACT PERSON/PHONE: +; � Z 14 - -�p4v LOCATION OF SERVICE: p� �',��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 iReduced Pressure Principle '1Red�iced Pressure Principle-Detector DQDoubleCheck Valve iDouble Cl�ecl<-Detector i I Pressurc Vacuum Breaker ?Spill-Resistant Pressure Vacuum Breaker ztr Manufacturer �S Model Number ��'� M I [a�T _Size Located At I� .��kC�2.lr1 {�,, ��rC 1�p��,�,�� Serial Number h\ z�Ci�nc( � Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e.S 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' i Closed Tight � I psid psid psid Leaked; I Leaked� i 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 Ciosed Tight! I Closed Tight I psid psid psid Test gauge used: Make/Model SN: Date Tested for Accuracy: Remarks: N� -TE�'[E p � � �'7 �r �'-�{Z�C-��p�a The above is certified to be true at the time of testing. Firm Name Firm Address Certified Tcster(pr�nr) Certified Tester(signature) Firm Phone# Cert.Tester No. 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