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2017_0925 IRRIGATION � DOMESTIC FIRELlNE 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: I 30 (/J t� r Cj� �� X CONTACT PERSON/PHONE: vi . ZI - 4 ' (��O LOCATION OF SERVICE: 2(0� � e5 ��v 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 -iReduced Pressure Principle-Detector 1ti9Double Check Valve ':Double Check-Detector I 1Pressur�VacuumBreaker iSpill-Resistant Pressure Vacuum Breaker Manufacturer WQ�-�5 Model Number �7�/ Q`T Size z�� Located At �O�.c�L D-� 5 C�vv� Serial Number A �� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Ve5 • 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 Z�3 psid Held at Z�4 psid Opened at Opened at Held at Initial Test Closed Tight64 Closed Tight i34' psid psid psid Leaked! I Leaked' ; 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 ClosedTight' ; ClosedTight I psid psid psid Test gauge used: Make/Model l�W1C�ro.cU `�D-- Z��TK SN: ZS�OC�Q Date Tested for Accuracy: -/ 1�_� Remarks: The above is certified to be true at the time of testing. Firm Name l,p�p(J�� j�D Firm Address 13b3�� etl �� Certitied Tester(prznt)� V�� I��Certified Tester(signature) � Firm Phone#_�.j�( - �f l�C," �d� Cert.Tester No.11T Q��7Sg 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 assemb(y 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) MAILINGADDRESS: � ',.� � t^ Y ��,r �II �C CONTACT PERSON/PHONE: c�; " t - 4 lo-- '-I LOCATION OFSERVICE: 2�U �du.,-�1�� -��v'R �`lvc� 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 ��Reduced Pressure Principle-Detector 'p4DoubleCheckValve 1Double Check-Detector ' I Pressur�Vacuum Breaker i Spill-Resistant Pressure Vacuum Breaker Manufacturer ��[�CC� Model Number �fs^0 Size �r� Located At �2�a1�'T Serial Number 1� �C'�Z� Is the assembly instalied in accordance with manufacturer recommendations and/or local codes? eS 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 Tighti iK Closed Tight ��t psid psid psid Leaked� I Leakedl 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 Closed Tight' I Closed Tight' ! psid psid psid Test gauge used: Make/Model�.vMbt�x�a �0�-Z�� SN; Z 5�p 00 Date Tested for Accuracy: 9�/� �/7 Remarks: The above is certified to be true at the time of testing. Firin Name �� —�—s� Firm Address 3�3 l�� '8� ��'. Certitied Tester(pt-�nt) QV ic.%� . �' Certified Tester(signature) �/ 1 Firm Phone# �� Cert.Tester No. ��Date 7 �'� l? * 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