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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: t3�3 (�rc�n5 �� r• ��t-'1� ��x CONTACT PERSON/PHONE: ; i Z�`l - 49(a -�'C�4 U LOCATION OF SERVICE: i 201 Wro.nq,e✓ ;� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable para�neters. TYPE OF ASSEMBLY 1QReduced Pressure Principle '-IRedticed Pressure Principle-Detector � IDoubleCheckValve �Double Cl�ecic-Detector ; I Pressur�Vacuum Breaker !Spill-Resistant Pressure Vacuum Breaker Manufacturer �a'�'�S Model Number ��0�'/�Z- Size � ��- Located At Q��li2. ��✓� Serial Number �� Is the assembly installed in accordance with manu acturer recommendations and/or local codes? i/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�Zpsid Opened at Opened at Held at Initial Test Closed Tightf i Closed Tight �1 psid psid psid Leal<ed' I Leakedl i Did not open I Did not open ! Leaked � Repai rs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' i Closed Tight� I psid psid psid Test gauge used: Make/Model ��o SN: �9 �� Date Tested for Accuracy: � � Remarks: The above is certified to be true at the ti�ne of testing. j� ' 'C l 3 a3 (,J ra n �, FirmName (J1 Firm Address � ►� � n Certitied Tester(pr�nr) U'1 Certified Tester(signature) Firm Phone#��`t �`t-/�v �O�'7� Cert.Tester No.f��pD6�s 8 Date / zs � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yel(ow-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: l 3 03 �r�nc�ip�G�' CONTACT PERSON/PHONE: (�p i ;c� i`f� +-� (o-- '!�'`� LOCATION OF SERVICE: t Z�1 �n E,� 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 yiDouble Check Valve "�Double Check-Detector '1 Pressur�Vacuum Breaker -,Spi11-Resistant Pressure Vacuum Breaker Manufacturer re�� Model Number �s^V Size �Z Located At NQ2'`(� O�F (Q�i�1 Serial Number G-�C��s1� Is the assembly installed 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 Check Held at z�1 psid Held at z�`f psid Opened at Opened at Held at Initial Test Closed Tight��4 Closed Tight I�' psid psid psid Leakedl I Leakedl i Did not open � I Did not open ! Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' i Closed Tight' I psid psid psid Test gauge used: Make/Model C.o�n^bt�C.0 �O--Zm�T�- SN. Z�� Date Tested for Accuracy: qT�d L�1 Remarks: The above is certified to be true at the ti�ne of testing. � FirmName �p�� S'p Firm Address �3�'�S�✓�M�9leY' `✓', CertitiedTester r�nt J� � �� , (p � ) � 'C� �t�� Certified Tester(signature) Firm Phone# �� -4�1�0 �� Cert.Tester No.l�► E�f�t�Xo��j� Date�s 17 * 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