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2017_1031 i --- � . - ---_ IRRIGATION k 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 MAIN TENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: �3�3 i,�m.v� �e/ �`r � �e l� TX CONTACT PERSON/PHONE: o.v id cs.; Z i�{ - 10��(�yp LOCATION OF SERVICE: � �� 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 �"7Reduced Pressure Principle-Detector �Double Check Valve �7 Double Check-Detector ❑PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker Manufacturer 1'�� Model Number $� � Size �� Located At �fe�-� c� c..�� e-� Serial Number �-� �Q(o�( ( Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Je5 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 Z� �psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight I?� psid psid psid LeakedC� Leaked,�l Did not open C 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❑ Closed Tight��_� ps�d psid psid Test gauge used:Make/Model �-c�rv�brt��.C� �{'O•-��- SN: ZS-a�� Date Tested for Accuracy: �(��17 Remarks: The above is certified to be true at the time of testing. Firm Name�ppe�� `� w Firm Address �� t�' �►"• � �� Certified Tester(print) cZviC��I Certified Tester(signature) �� Firm Phone# 2��-�� '�_Cert.Tester No. PP00��P7�S Date �� 7 *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ��USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-Ciry 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 I.D. #0570040 (Customer) MAILING ADDRESS: l 3 0� ��anq f ei r �p pe(� "-")C CONTACT PERSON/PHONE:�Q��`d ; �, '�.I y-�{q(o —�(�y�v LOCATION OF SERVICE: (�5 N, (�6�►��'�L., n �; ,� p .�r ��e,.n 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 �bC�O Model Number C�� Size �� Located At_�prt-� p� �Jchobl '� Serial Number �� d�'�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ye5 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�5 psid Held at ��'� psid Opened at Opened at Held at Initial Test Closed Tightf� Closed Tight�J psid psid psid Leaked❑ 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 Closed Tight C� Closed Tight i l ps�d psid psid Test gauge used:Make/Model�r�'1 brr�Lc> '��'-� �� SN. Z��pC,� Date Tested for Accuracy: �t'I��(7 Remarks: The above is certified to be true at the time of testing. Firm Name L�Ope.�� Firm A ddress �� 'et�' �--�r � e�i � Certified Tester(print) U i � Certified Tester(signature) � Firm Phone# 7il`(��I� �D`�v Cert.Tester No. U�0�67�� Date �� ll� �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