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2015_0925 (3) 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: I 3O3 rGt CY CONTACT PERSON/PHONE: u f S �eGI.�S Z�I `�i(o`�v�� LOCATION OF SERVICE: i 30 t 1,Jf+pt�'1G� ei�' �r e-N�S � 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 7Reduced Pressure Principle �'Reduced Pressure Principle-Detector �Double Check Valve C Double Check-Detector C1PressureVacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker �Q� S �� 1 l�C� Size Z11 Manufacturer � Model Number Located At �1�t.-�'`ei''� Serial Number � 2��Q � Is the assembly installed in accordance with manufacturer recommendations andlor local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air lnlet Check Valve 1 st Check 2nd Check Held at��psid Held at ( �� psid Opened at Opened at Held at InitialTest ClosedTightlyl' ClosedTight bC' psid psid psid Leakedl ' Leakedf ' Did not open . I Did not open I I Leaked' 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�rnbr�w �b� �a T� SN: '�`�d C'b Date Tested for Accuracy: �� I� Remarks: The above is certified to be true at the time of testing. , � FirmName ��P��1 �� Firm Address (3� �'� �et/' 1� Certified Tester(print)�U 1� 11-X�� Certified Tester(signature) � Firm Phone# Zi��'"�b�� Cert.Tester No. �7��7s� 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 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 LD. #0570040 (Customer) MAILING ADDRESS: �3�3 �r�n�ev -1✓ C-�pAe�� 5e1`� CONTACT PERSON/PHONE: t-ou�5' �� S ��`� -y q�^ O`}b LOCATION OF SERVICE: I � b ( ra o' i Y' M 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 1Reduced Pressure Principle I�'Reduced Pressure Principle-Detectar I�d'Double Check Valve 1 Double Check-Detector �PressureVacuumBreaker I ISpill-Resistant Pressure Vacuum Breaker ,� .Zr► Manufacturer �C-'��-o Model Number �� Size Located At �'�L� �5��"�d ��n^� o�' �C- Serial Number �� D�13� 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 Z'd psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tight!'� Closed Tight �7 psid psid psid Leaked` i Leaked�l Did not open f I Did not open ` � Leaked I 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 �r"��rOp `l� '✓��0�K SN: Z��b Date Tested for Accuracy: �� f 'rJ Remarks: The above is certified to be true at the time of testing. 1� 1�jQ� W r�r1 �e►'Li Firm Name�ApO'e I 1 �—�� Firm Address Certified Tester(�r:nt) �V 1��t��'�'1 Certified Tester(signature) �� * �j, �1 �/ /� % q � � Firm Phone# �� l '�l��'�QT� Cert.Tester No.b/��/� Date / �'� �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 for each assembly tested. A signed and dated original must be submitted to the public water supplier far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) � � � �` � ��( �x ,,,7�� MAILING ADDRESS: � 3 l��ar�q er � r CONTACT PERSON/PHONE: u'S QGi.q�, Z 1 '�q -�,0�'� LOCATION OF SERVICE: I �0 1 l,t)�YJI�"l�i el'r c-�5 �� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operaring within acceptable parameters. TYPE OF ASSEMBLY -1Reduced Pressure Principle r 1Reduced Pressure Principle-Detector f�oubleCheckValve 7Double Check-Detector � 'PressureVacuumBreaker I Spill-Resistant Pressure Vacuum Breaker l��-S d0�1 fY1� Q I Size Z�` Manufacturer Model Number Located At �QS� b� �pM� 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 Tight��}X� Closed Tight 1�- psid psid psid Leakedf I Leakedl 1 Did not open � I 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� I psid psid psid Test gauge used: Make/Model��^��D �d�'�0 ��' SN: �-`�`�d� Date Tested for Accuracy: � (�� S Remarks: ' � The above is certified to be true at the time of testing. FirmName�-0�� -�� Firm Address ��b� �t�a �er ��Y . � Certified Tester(prir�t)�C�V fd �t�l°t'1 Certified Tester(signature) Firm Phone# �`[ " ��$�� Cert.Tester No. �l ��v7S$ Date � Z� �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