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2015_0903 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 MAILING ADDRESS: �� G �� 5�� r' Zy� y�O �,Z y6 CONTACT PERSON/PHONE: /u ' S c P�9" LOCATION OF SERVICE: 6 X l� 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 CReduced Pressure Principle-Detector I�QDouble Check Valve �i Double Check-Detector �1PressureVacuumBreaker I �Spill-Resistant Pressure Vacuum Breaker ,- !� Manufacturer r� B� � Model Number � �� Size a Located At �• �� C�� e� Serial Number a � �l'Z 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�a psid Opened at Opened at Held at Initial Test Closed Tightf�l Closed Tight}Q psid psid psid Leakedf�1 Leaked�� Did not open I�I Did not open I I Leakedf�� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight-] Closed Tight� l psid psid psid Test gauge used: Make/Model CD��°��v � ��, SN: a�s'd��l T l�� Date Tested for Accuracy: 3� �l Remarks: The above is certified to be true at the time of testing. I�c.��D � f'!� t �c�./3c��C 7�t 7 G��X.q. 7�_ Firm Name Firm Address � � � Certified Tester(pr�nt)��" �� Certified Tester(signature) Firm Phone# �� °� � 7 Cert.Tester No�3�Do0 7d''� Date � 3�� * T'EST 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) t� Ma1LiN� aDDREss: �°� �� s�e_ �oG �"�-�/. � w- �lG.��i o CONTACT PERSON/PHONE: �� 5 // �� / LOCATION OF SERVICE: �o� - �oVj1 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 IReduced Pressure Principle-Detector i�oubleCheckValve IDouble Check-Detector '1PressureVacuumBreaker :�Spill-Resistant Pressure Vacuum Breaker �(/ f�S �i Manufacturer � Model Number G�7�� Size � /�'l e��,L / � s7�y Located At Serial Number 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 lnitial Test Closed Tightly�l Closed Tight �(I psid psid psid Leaked� I Leaked I Did not open �! Did not open [.�� Leaked��I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at _ Repair ClosedTight I� ClosedTight f 1 psid psid psid �D� Test gauge used: Make/Model ��'�``�� ' " �� SN: Q G O�/7�d Date Tested for Accuracy: � � �' l Remarks: The above is certified to be true at the time of testing. � � FirmName�c ��O�'�' � �� Firm Address ��"�3� Y 7 � 7 ��'�` �x �f /�� s Certified Tester(pr:nt)�� `� w' � ��u Certified Tester(signature) �� Firm Phone# ��s�� a�'� Cert.Tester No.l3�0O°D7 v� Date 7 " 3�"l S * 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 far 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) f(� �/��!�� MAILING ADDRESS: G �� 5��_�� -��"`� ��• CONTACT PERSON/PHONE: � �� LOCATION OF SERVICE: ��a�,/�� 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 CReduced Pressure Principle-Detector �Double Check Valve ��Double Check-Detectar �PressureVacuumBreaker i=Spi11-Resistant Pressure Vacuum Breaker Manufacturer �43 ��f Model Number �� aN � Size a ', Located At ��P� Serial Number f � 7 �S � Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? � �S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve l st Check 2nd Check Held at l $ psid Held at �'� psid Opened at Opened at Held at Initial Test Closed Tight�l Closed Tight �� I psid psid psid Leaked'�. ; Leaked'.1 Did not open f�'� Did not open f I Leaked' �� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight[- Closed Tight C psid psid psid v/ ��co /�'`� C�G o Y/T�a Test gauge used: Make/Model C�r� SN: Date Tested for Accuracy: 3 -� Remarks: The above is certified to be true at the rime of testing. FirmName �C��N' �� t Firm Address ��` �� 7 p7 ��X� ~ �x` �r X � t l/� �' Certified Tester(print) � � � �j Certified Tester(signature �� Firm Phone# g�� ss� �a �� Cert.Tester No. �3�DDOo 7 D� 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 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) ,.� � MatLIN� a��xEss: G D � C. �G s��e. ��o ��.- �i�� /G�y� CONTACT PERSON/PHONE: � S l P� 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 CReduced Pressure Principle I Reduced Pressure Principle-Detector ' 'Double Check Valve �CDouble Check-Detector ':;PressureVacuumBreaker �'�Spill-Resistant Pressure Vacuum Breaker �� Manufacturer �/P� S� Li Model Number � C� Size g 7 Located At /�'. �- U�v �� Serial Number �d � 3� y Is the assembly installed 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 3'`� psid Opened at Opened at Held at Initial Test Closed Tighttil' Closed Tight I�l psid psid psid Leaked'�� I Leakedl I Did not open �.1 Did not open �� 1 Leakedl��I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight��1 ClosedTight I I psid psid psid Test gauge used:Make/Model C� ��C� �6��`� SN: �� Y17�� Date Tested for Accuracy: 3��' —� Remarks: The above is certified to be true at the time of testing. Firm Name � GT�4�% �� Firm Address � �f �GX 7� 7 ��'�'�` �x Certified Tester(pr:nt)/�� `� ��'` � Certified Tester(signature) ��' Firm Phone# �� '�� Cert.Tester No.l��d��"� 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 recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) �� MAILING ADDRESS: � � ' �- �� U —�� G'� �� CONTACT PERSON/PHONE: �� S � P� LOCATION OF SERVICE: S, � v/t/ 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 C Reduced Pressure Principle 1Reduced Pressure Principle-Detector �`Double Check Valve i �Double Check-Detector C_IPressureVacuumBreaker I �Spill-Resistant Pressure Vacuum Breaker Manufacturer ��E'� S A S/ Model Number J�/J � Size ;�Y Located At I�� C , �/�v �� Serial Number Ca`' �`�K � �e�c� Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? r/ � -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�"� psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight� psid psid psid Leaked'i 1 Leakedl � Did not open [1 Did not open f�I Leaked I Repairs/ Materials � Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight_] ClosedTight[1 psid psid psid Test gauge used: Make/Model C� ��'�� Y�� SN: d��`�ll �� Date Tested for Accuracy: �` � �� Remarks: The above is certified to be true at the time of testing. FirmName �C��a�' �� Firm Address �0- ��o� �� 7 �'��_ �� Certified Tester(prFnt) �"`� �� Certified Tester(signature) � � Firm Phone# ��0�s�� `�'� �� Cert.Tester No.�'��g�� 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 I.D. #0570040 (Customer) t� ��Q MAILING ADDRESS: � � d �• Cl � 5�e' l�� ` �� y CONTACT PERSON/PHONE: � 5 t � �� LOCATION OF SERVICE: c� S� o f/p The backflow prevention assembly detailed below has been tested and maintained as required by commission regularions and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY I '�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector ClDoubleCheckValve �Double Check-Detector �PressureVacuumBreaker � ISpi11-Resistant Pressure Vacuum Breaker �i Manufacturer �� S � L/ Model Number �� -� Size $ Located At � �� Serial Number y 30 � Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? �f 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 o�•� psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight}C� psid psid psid Leaked I Leaked I Did not open l Did not open ' Leaked ''� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTightll ClosedTightC�� psid psid psid Test gauge used: Make/Model �� '�� y'` �� SN: ��d �� 7�� Date Tested for Accuracy: 3-�' � Remarks: The above is certified to be true at the time of testing. FirmName /i C��a� � �K c Firm Address ��'�U � 7 �, �� Certified Tester(pr:nt)�� Certified Tester(signature) �� Firm Phone# $��-ss� �`'�a � � Cert.Tester No.��?�'� 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 IRRIGATION DOMESTIC FIRELINE 1�+ The following farm 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: � �'� �' - `��' � ��' . /��' �� -�'�- c��'�� CONTACT PERSON/PHONE: � S � �/�- LOCATION OF SERVICE: ;� O �� The backflow prevention assembly detailed below has been tested and maintained as required by commission regularions and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY I�1Reduced Pressure Principle I IReduced Pressure Principle-Detector I�ouble Check Valve CJ Double Check-Detector ClPressureVacuumBreaker ' 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer /� �x S�' l,/ Model Number ` � C Size /y Located At /V ' U�v l � Serial Number �� '�g� Is the assembly installed in accardance with manufacturer recommendarions 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 I � psid Held at /� g sid Opened at Opened at Held at Initial Test Closed Tightf� Closed Tight� psid psid psid Leakedl�I Leaked�� Did not open I�I Did not open '1 Leakedl�� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I i Closed Tight� psid psid psid Test gauge used: Make/Model CD/��"��U y ��U SN: ��7 �� Date Tested for Accuracy: �� l Remarks: The above is certified to be true at the time of testing. n �l 7 �li�� -�� 7S/� � Firm Name !7 G�� " � Firm A ddress ��'�3�X Certified Tester(prfnt) �� - �' �� 5 Certified Tester(signature) Firm Phone#�� SSU�aa � 7 Cert.Tester No.��40�0 ��'Z" 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