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2014_0911 C�IECK ONE: IRRIGATION DOMESTIC /` FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR? NAN�OF PWS: CITY OF COPPELL PWS I.D. # LOCATIOIv'OF SERVICE: � �'� .� ����� The bac�low pr�veation asscmbly detailed bclow has beea tested and n+a�nta�ned as required bv TNRCC re_¢ulaaons and is cenified to be operating within acceptable parameters. TYPE OF ASSEMBLY c Reduced Prassure Principle e Pressure Vacu�Breaker � Double Chxk Valve p Atmosphere Vacuum Breaker Manufacturer Gc�`rt ��j s� � , Model Number f�0 I�l � Locaud At ��'��� Serial N�ber � //�' 3� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R Double Check Valve Assembly lst Check 2nd Checl: Relief Valve Air Inlet Check Valve Inival Test DGClosed Closed Ti�t :1S Opened at Opened at osid Tisht C• � � Lcal:ed�,� ❑ nsid osid RP-_psid �;� p Did not Opca o Leal:ed J �P� and Mataials Used Test After DGClosed Closed Tight o Opeaed at Opme�at nsid Repair Tight ❑ osid osid R.P sid The above is catifiod to be true. Firm Name �c �'aa- �/K f CertiSed Testa /�'�� ��� C��� //��� s� Firm Addres.s �v 3" y 7�7 C�/y�`�'�-7"xCert Taster No. ����v�Ia.:� Date �// ^�S� (3auge # Q G�✓'�=//T�� llate last accuracy tested � ���-�� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy C�IECK ONE: IRRIGATION " DOMESTIC FIRELINE � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAIv�OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: � /�� S �° I�/s!/ The bacictlow prevcation asscmbly detailed below has beea tesied aad n'+—a�ata�*�ed as required by TNRCC regulauons and is certified to ba operaring within acccptablc paramtters. TYPE OF ASSEMBLY C Reducrd Pressure Principle ❑ Pressurc Vacuimi Breaker �Y Doublc Chxk Valve a Amiospherc Vacuum Breaker ;� Maaufarnaer �/4 f '� Siu `� Model Number � � y Locatcd At U''�v�� /��" `'�D"��" Scrial N�ber l��`? T 4/ REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAKER Double Check Valve Assembly lst Check 2nd Checi: Relief Valve Air Inlet Checic Valve Inival Test DGClosed Closed Ti;ht � Opeaed at Opened at osid TiQht � � � Leal:cd �%1" ❑ nsid nsid RP-_,psid Leaked o Did not Opea O Leal:ed o �P� and Mataials Used Test After DC-Closed Closed Ti,Qht o Opened at Opeaed at _osid Rcpair Tight ❑ csid osid RP sid The above is certifi�to be true. Firm Name J�c�i�i�m�� /%�t/" CeRified Tester /�A �� ����i/9�s Firm Address ��� �3o y 7`r 7 ��x�- T� Ccrt. Tester No.���a ao��-z D� � -%/ �i f� Gauge # �G O G//T YG> llate last accuracy tested � -��`y White- Customer's Copy Yellow - City Copy Pink-Tester's Copy C�IECK ONE: IRRIGATION DOMESTIC FIRELINE J�� BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINI'ENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: � j� � l/��Y/¢ The bacl�low preveation asscmbly detailed below has bcen tested and ma��ta�ned as required bv TNRCC regularions aad is ceitified to bc operating within acr.eptablc paramcters. TYPE OF ASSEMBLY C Raiuced Pressure Principle C Pressure Vacu�Brealcer '� Doublc Chxk Valve [7 Atmospherc Vacuum Breal:er Manufactsaer ���i5' �Ts Siu ' ;y Modei Iv�ber � �',`��'� Locaud At ����'�� !vt- ��"�" � Saial N�bcr / � `"� l� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAI�R Double Check Valve Assembly lst Check 2ad Checl: Relief Valve Air Inlet Check Valve Inidal Test DGCIos� Closed Ti�Qht. � Opcned at Opeaed at nsid Tisht /' � � Leal:cd !. CG ❑ nsid osid RP-_psid Leai;ed o Did not Opea o Leal;ed o �P� and Materials Used Test Aftet DGClosed Closed Tight o ppeaed at Opeaod at _nsid Repair Tight � nsid __osid RP sid The above is cerdfiod to be true. Firm Name��-�e�w f//�<' CertiSed Testa ��� G�/t�/�°��t S Firm Address ! �'b'U i� ,7�7 C���X�'1- � Cert. Tcster N0. /��0����'�,.z Date �`���/y (3auge # �1 fj�`'`1�17�!p llate last accuracy tested � ��7 ���1� White - Customer's Copy Yellow - City Copy Pink-Tester's Copy C�iECK ONE: IRRIGATION � DOMESTIC FIRELINE BACI�ZOW PREVENTION ASSEIV�LY TEST AND MAINTENANCE REPORT NAN�OF PWS: CITY OF COPPELL PWS I.D. # LOCATION OF SERVICE: � �� S ��{��� , The bacl�-tlow prevmtion asscmbly decaile� below has bcea tcsted and ma�nta�n� � nq�� bv TNRCC regulacions aad is cerdfied to be operating within acceptable parameters. TYPE OF ASSEMBLY C Rcduced Pressurc Principle ❑ Pressvrc Vacui�Breaker 'S Double Check VaIve p Atmosphere Vacuum Breal:er Manufact�er ����� Siu � !s Modei Ivumber �� S p Locat�d At i�Z r ��k Serial N�ber ��`'�' �/ D REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R Double Cherk v alve Assembly lst Checl: 2nd Checl: Reiief Valv� Air Inlet Check Valve Ininal Test DGClose� � Closed Ti�t p Opened at Opeaed at osid Ti�t � � Lcal:ed iyL o nsid _nsid RP-_,psid I,cal;ed ❑ Did not Opea O Lealced o �P� and Mataials Usod Test After DC-Closed Closed Tight o Opened at Opeaed at �nsid Repair Tight ❑ Dsid nsid RP sid The above is certified to be true. Fiim Name �����o�- f'/�e r' Catified Tester .�'� I��c° C�;���i r7� s Firm Address����''� 7� 7 ���'`�`�'� �� Cert. Testa No. /��O��0 7 U..� D� � -!i-/ Gauge # lJ G �t!/��l� llate last accuracy tested j -��� �y White - Customer's Copy Yellow - City Copy Pink-Tester's Copy Backflow Device Test Report Rermit#: Date: ` Backflow: ❑Reg ❑Not Reg ❑ Lic exp O Residential �Commercial O New Assembly xisting Assembly [7 Repair of Existing Assembly Job Address: � • G,\ -�, � System Owner:�� Assembly Location; �T �(�� �v, � a��� rF�: jAa,;k;i :r� �n>_,:�'`d`it)fJ!'tSSFA�t�3 1 i..';If (j c3E__C)`�;l r{Fj.`7 F.E`N T�-.."F.`)�.'�lEi C'at�;Etvl-il"J� ():�-;•ii_.,JI, ''f : ,,; C�;'t ;, R�(-�(JI A i:�N`_� �l�l�`i I''i C1EP,TlFi )T.�1'r�� C}¢�t�::4-i�'�.I Ihl�:�V�;1TI_��II\i=,(,�,F�'?l;t�l� ':S,Ft,;'F`=��.� � TYPE OF ASSEMBLY � Reduced Pressure Principle a Pressure Vacuum Breaker � Double Check a Atmospheric Vacuum Breaker Manufacturer: _�_�_)L`��'J Serial Number. l` ���� Model Number: � \� � UJ� Size: �t 1 Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure Vacuum Breaker 1st Check 2ntl Check Relief Valve Air Inlet Check Vafve Initidl Test DC—Closed Tight Closed Tight Qpened At: Qpened At: � RP- si psid psid ` �� �(j� Leaked psid Lea�, �� Did not open Leaked Repair ReDairSJMaterials Used: DC-Ciosed Tight Closed Tight Open At: Open At: Teat After Repair RP- _�sid psid psid psid Pass ❑ Faii � Certified Tester. ������.5 ���((1'.�'e 2.. Contractor Name: _�1��� Tester#: W � D Contractor Address:(�r,c���a���j� �j1�� Signature; Contractor Phone:���—p�a�-� —�� Zj�� Revfsed 10/12 Backflow Device Test Report Permit#: Date: Backflow: ❑Reg ❑Not Reg ❑ Lic exp ❑ Residential ommercial O New Assembly xisting Assembly ❑ Repair of Existing Assembly Job Address: . � 1 � '�' System Owner. ` Asszmbly Location:� (�-+�Y`� �� ��,�, N; sA{;!�'�; '`�'d'J�tiL'J�NTEC;�P^! �'�`i.`�E�/EF3;.Y l_I`;il !):3E:�Ci�. ,-'f",,:`i P.F�N TF 3�E,�)n,`!(:�(,fi,illvtA?rv;:::l'?;��E i, k1C ::s , ,:;€': R�[',l)I A:�I��I4S�IJ?-i I��[sEP,T(FI��)T i;3E C)i'L�f1.+1�R�E.�VvriTl{�N t0' t.E �i�,r,l_ Pr=.F�� ,"F T�4�t> TYPE OF ASSEMBLY ❑ Reduced Pressure Principle a Pressure Vacuum Breaker � Double Check � Atmospheric Vacuum Breaker Manufacturer. \ �). � Serial Number: 1�.��'C� o�� �a 3�� �� Model Number: Size: Reduced Pressure Principle Assembly/Double Check Valve Assembly Pressure Vacuum ereaker 1st Check 2nd Check ftelief Valve Air Inlet Check Valve Initiai Test DC—Closed Tight�!_ Closed Tight � ^ Opened At: Opened At: RP- psid psid psid Leaked psid Leaked Did not open Leaked Repalr RepairslMateriats l�sed; DG Closed Tight Closed Tight Open At: Open At: Test After Repair RP- _�sid psid psid psid Pass � Fail ❑ Certified Tester. 1�{`��S `\/ Y��—�Contractor Name: �`"�► ' Tester#: � (� Contractor Address:r�XQ�LI �`-'' � �V[,s� �J1�C'Jl Signature: Contractor Phone: ���—p�.�:����) a kevisetl SO{12