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2016_1213 �' IRRIGATION DOMESTIC FIRELINE v 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: td � CONTACT PERSON/PHO E: 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 C�Reduced Pressure Principle-Detector ❑DoubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker :�Spill-Resistant Pressure Vacuum Breaker �!,�� Q,�,� u Manufacturer �J Model Number �kJl.1 �7l`�l(J� Size � Located At ��C�K. �� Serial Number .L� � _.�D7 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 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�, Closed Tight� psid psid psid Leaked�-1 Leakedr'� Did not open .l Did not open � LeakedL J Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used: Make/Model V��V�-�1� � SN: �`^� 1�� Date Tested for Accuracy: �� Remarks: The above is certified to be true at the time of testing. �' � `n��- FirmName '�h�� U�� Firm Address IVTJ� � ��'Q��'is �� • �^ .• Certified Tester(print) 1F � Certified Tester(signature) Firm Phone#�I��1��- q�.U� Cert.TesterNo. � l� 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 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 LD. #0570040 (Customer) G � 2 MAILING ADDRESS: —�Grt�4�L J CONTACT PERSON/PHONE: 1�E�L ' 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 `IReduced Pressure Principle-Detector �ouble Check Valve i I Double Check-Detector C!PressureVacuumBreaker '-'Spill-Resistant Pressure Vacuum Breaker � �,�,n a Manufacturer Model Number l�e�!/��3 Size 3 ' Serial Number �4«�.. Located At ��, Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve l st Check 2nd Check �j5 Held at �•D psid Held at ��l� psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked' � Leaked Did not open '-' Did not open '. I Leaked� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight Cl Closed Tight�7 psid psid psid Test gauge used: Make/Model 1 �-(� SN: �� Date Tested for Accuracy: �I�- � Remarks: The above is certified to be true at the time of testing. -'��vN'r�� W�1`�� Firm Address �� FJK��Jl(�� I�c/� Firm Name (�• Certified Tester(print) �l+�l[�i{i��(2-�( Certified Tester(signature) � Firm Phone#��)�"`�- -L�� Cert.Tester No.��p��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