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2017_1031 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) � MAIL�rG ADD�SS: �3c�31�.��^o.n ��" C:�' � �' �X CONTACT PERSON/PHONE: ' i Z� '`��1�v' 8C�`-4U LOCATION OF SERVICE: 5 � The backflow prevention assembly detailed below has been tested an 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 �ouble Check Valve I 7Double Check-Detector ❑PressureVacuumBreaker !�Spill-Resistant Pressure Vacuum Breaker Manufacturer W i��1�f15 Model Number !50 `?(LT Size � �lZ. Located At N, �,r{�� OF��[�4 � Serial Number S��(o� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �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 3..2 psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked.i Leaked❑ Did not open [7 Did not open ' 1 Leaked-1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight f 1 psid psid psid Test gauge used: Make/Model �i'►'►�►'�w �- �T'� SN: Zv�QUC:� Date Tested for Accuracy: G�'f �1�f� (7 Remarks: The above is certified to be true at the time of testing. FirmName l._o�� -5� Firm Address f3�.� �2��'t9I� �� '�-°(/ —� Certified Tester(print)�GZ(i `� �� Certified Tester(signature) ` � Firm Phone# u`f -�Q�v�� Cert.TesterNo. ��lSB Date /B 3/ l f 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 recordkeeping purposes: � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) �� ( � MAILING ADDRESS: 13�7 L-i r CONTACT PERSON/PHONE: v� 1 y -`� -��4'� LOCATION OF SERVICE: SS �cJ. e c � � 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 I�Reduced Pressure Principle-Detector fj�Double Check Valve ''1 Double Check-Detector ❑PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker r � ,�^�,,..� .Z�► Manufacturer v..A� Model Number �� cX 1 Size Located At � 5i d� ��aa Serial Number � �1 �o �� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Y�� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve � I st Check 2nd Check Held at �� psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tight y Closed Tight IN psid psid psid Leaked i Leaked`�� Did not open ❑ Did not open I 1 Leakedl 1 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 l�►'►�� '`��'"�� 1L SN: �� Date Tested for Accuracy: �I l�S'�7 Remarks: The above is certified to be true at the time of testing. FirmName ��(Je� � �—�� Firm Address `�� I�'' ��r � �1 Certified Tester(print) - �� Certified Tester(signature) � � Firm Phone# U'f—'[��—�� Cert.Tester Na P� 7s� Date �� 3� /� * 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