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2015_1105 IRRIGATION DOMESTIC 'C FIRELINE � The following farm must be completed far each assembly tested. A signed and dated ariginal 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) i __ MAILING ADDRESS: �.3 ��r �l � CONTACT PERSON/PHONE: ` ZI - Io LOCATION OF SERVICE: S r The backflow prevention assembly detailed below has bee tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY f]Reduced Pressure Principle �r�Reduced Pressure Principle-Detector '�boubleCheckValve �7Double Check-Detector -7PressureVacuumBreaker lSpill-Resistant Pressure Vacuum Breaker I , f Z// Manufacturer I�IJQT 5 Model Number �7/7?� � Size Located At ,��P_ J`1Q��W�f�'1 ��lT� CI�- Serial Number ��`�J�J 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 V alve 1 st Check 2nd Check Held at�r�psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tightf� Closed Tight �� psid psid psid Leakedl�1 Leaked�I Did not open [ I Did not open � 1 Leaked I I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight I I GosedTight�_1 psid psid psid Test gauge used: Make/Model M�rACo �{O- ��L SN: ��O�U Date Tested for Accuracy: 'Z Remarks: The above is certified to be true at the time of testing. Firm Name� e�/ �� Firm Address � � �/� �� % r Certified Tester(print) ' f Certified Tester(signature) Firm Phone# �� " ��10� Cert.Tester No. �Q��Date �� c5� * 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 aDDxEss: �3a3 Wra ,er (a� �o eil Tx CONTACT PERSON/PHONE:`e�u i`S I�Q G(US Z 1 —�,F`$� --R 0 S�U LOCATION OF SERVICE: I�'S ls�. �arI4�.Y.JE.`-1 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 ' 1Reduced Pressure Principle-Detector �pDouble Check Valve I Double Check-Detector C'PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker /� Manufacturer ��s Model Number �� Q7 Size �' Located At !��lJ�i'S ��1 i E� 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 Initial Test Closed Tightf� Closed Tight�9 psid psid psid Leaked I Leaked' I Did not open I 1 Did not open I 1 Leaked'i 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 Test gauge used: Make/Model �►'►'1�� b l`�— SN: '��id� Date Tested for Accuracy: ��Z� �S� � Remarks: The above is certified to be true at the time of testing. Firm Name�_Q�/l .L�'U Firm Address � B✓ �r J `' I " • Certified Tester(print) 'P� Certified Tester(signature) Firm Phone#�„��f—�7� —�� Cert.Tester No. / �i(.V�� 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) �� MAILING ADDRESS: 1�03 W� CONTACT PERSON/PHONE: w t" U Zl - — � 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 ��DoubleCheckValPenci le ��7ReducedPressurePrinciple-Detector .p �� 'Double Check-Detector �-iPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer WQT� Model Number ��7''�7 � Size 2+' Located At �eS� �D� �a�i t��'�. Serial Number ��D�OQ 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 ��Ti psid Held at�psid Opened at Opened at Held at Initial Test Closed Tightl5� Closed Tight�l psid psid psid Leaked! 1 Leaked��I Did not open [�1 Did not open � I Leaked I I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight.7 Closed Tight�1 psid psid psid Test gauge used: Make/Model lA/�1 Orc�CD ��" �� r��- SN: �Z��(�� Date Tested for Accuracy: ��Zb �/.� Remarks: The above is certified to be true at the time of testing. Firm Name � �� Firm Address J� � � Certified Tester(print) " I Certifred Tester(signature) Firm Phone# �� ' �� Cert. Tester No.��'W�� Date �� v� * 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: ��03 �r�t �$� ��►� �P�I� 1� 75��I CONTACT PERSON/PHONE: 1,.� Z/ —cf (o-S D 4�D LOCATTON OF SERVICE: `�S , f,�. �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 -1Reduced Pressure Principle �_�Reduced Pressure Principle-Detector I � ouble Check Valve � ��Double Check-Detector GPressureVacuumBreaker f 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �e��-O Model Number gS�� Size �� Located At �ron-F d �F Ch S Serial Number f7" as�� 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 2�� psid Held at Z�O psid Opened at Opened at Held at �� Initial Test Closed Tight� Closed Tight'� psid psid psid Leakedf 1 Leakedl� I Did not open I I Did not open 1 Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at • Repair Closed Tight f�-�� Closed Tight Ll psid psid psid Test gauge used: Make/Model �►'►'t �rG��r� �0�zQ0'�� SN: ��gb�d Date Tested for Accuracy: �l�-O��L✓'� Remarks: The above is certified to be true at the time of testing. z ' ` � i —� Firm Name �_ p�_�, �S� Firm Address ��J W✓� ►�' e/� �� Certified Tester(print) � �� Certified Tester(signature) Firm Phone# ��—�� Cert.Tester No.�k�! ��7�� 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 MAILING ADDRESS: S�'-� Wt`a►►'� � �'� �+✓ l� �I I —� CONTACT PERSON/PHONE: i �uS z► — `E � �-�304�(7 LOCATION OF SERVICE: S� Lc� rC.t,�Q 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 _�Reduced Pressure Principle-Detector y�ouble Check Valve C Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker J / Manufacturer �f�j�p Model Number �� Size 2 Located At en�'l i S �/!'I"$/ Serial Number �-t 3 �'3�5/ Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at Z� psid Held at 2�� psid Opened at Opened at Held at Initial Test Closed TightC7p Closed Tight� psid psid psid Leakedl��l Leakedl�1 Did not open I�1 Did not open 7 Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i� Closed Tight��J psid psid psid Test gauge used: Make/Model �M�-O�Cd �0--Zd�""� SN: Z�g�4 Date TestedforAccuracy: ��Zb�dS Remarks: The above is certified to be true at the time of testing. Firm Name �ppP�� cj�. Firm Address � CC� 'eI� �O Certified Tester(print) Q� 1U Q Certified Tester(signature) � Firm Phone# �-��—�� Cert.Tester No. ��p�c5� Date � � J * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White- City Copy Yellow-Customer Copy Pink-Tester's Copy � IRRIGATION � DOMESTIC FIRELINE The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping purposes: BACKFLOW PREVENTlON ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) � MAILING ADDRESS: �� '� �a' �a� �Q� eI � ��4 CONTACT PERSON/PHONE: euJ�S _ �e�a V,S z�4—�f�76—�'p� LOCATION OF SERVICE: _1$�' ��^tWa�y 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 �Reduced Pressure Principle-Detector �iDoubleCheckValve ❑Double Check-Detector � �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker !/ Manufacturer �� !� Model Number �� Size z Located At ��a� O�/�/u�fi� �ccrpo�� Serial Number �� 9 � � 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 Inlet Check Valve 1 st Check 2nd Check � Held at �s� psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tight�)'P Closed Tight,'KI psid psid psid Leakedf] Leakedl � Did not open �7 Did not open f.�I Leakedi � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight''_1 Closed Tight I 1 psid psid psid Test gauge used: Make/Model lsON1�Y�t.C.O �D'Z� � SN: ZcS�� Date Tested for Accuracy: l I �l�S Remarks: The above is certified to be true at the time of testing. Firm Name �p�� -�s� Firm Address � byJ �� C�I' �� o � Certified Tester(pr3nt) �� 1 Certified Tester(signature) G /'�, � Firm Phone# �-� ��L1 Cert.Tester No. � (O Date * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I l, �jr/I S **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) MAILING ADDRESS: �'�o� l�Jr'c�r°,�e►' �,� Cdppel) �jo CONTACT PERSON/PHONE:�t�S �lS 'ZI�—��i'lo — �'}O�{'� LOCATION OF SERVICE: I`6 S- LJ. ��[WC1'�y 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 "�Reduced Pressure Principle-Detector ?PDouble Check Valve �Double Check-Detector ��PressureVacuumBreaker _7Spi11-Resistant Pressure Vacuum Breaker Manufacturer W4�'cs Model Number �� Size ��I Located At �� "�� Serial Number (��J��d Is the assembly installed in accardance 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 Inirial Test Closed Tightl� Closed Tight C�� psid psid psid Leaked�. 1 Leaked��l Did not open �� I Did not open � 1 Leakedl�I Repairs/ �� f � Q V Materials Used Held at psid Held at�,�psid Test After � Opened at Opened at Held at Repair Closed Tight[� Closed Tight 7P psid psid psid Testgaugeused: Make/Model 1.0I'v1��tCp `�� ZDD� SN: zcS�g4� Date Tested for Accuracy: ��G S� Remarks: The above is certified to be true at the time of testing. Firm Name ""��-I 1 -�s� Firm Address �� le� � �I �1�' Certified Tester(print)�(�V�� Certified Tester(signature) � � Firm Phone# �/ � 1 /(p�� Cert.Tester No. ��lr�7 Date ' * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ��J[j J� �r **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 ariginal 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) 1.l /� MAILING ADDRESS: ( �O3 `^'rQt1 �� '� �-v �� CONTACT PERSON/PHONE: �2 i lu I — LOCATION OF SERVICE: • ar l,u 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 �^'Reduced Pressure Principle-Detector �Double Check Valve ��Double Check-Detector I'Pressure Vacuum Breaker '�-�Spill-Resistant Pressure Vacuum Breaker � ( y�/� � �� Manufacturer (�(,(`�'i's Model Number �Q��i� I �(�( 1 Size "� Located At�lt�T� �V t�r(�OSE..' S' � Serial Number � �'(��o�� 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�Q Closed Tigh� psid psid psid Leakedi�1 Leaked 1 Did not open . I Did not open i ; Leakedl�1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTigbt❑ ClosedTight C�.: psid psid psid Test gauge used: Make/Model � 1^ �� SN: � �� Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Firm Name � Firm A ddress �� v"� l E�' �`r �� — � Certified Tester(print) � Certified Tester(signature) Firm Phone#��–`'f�llv ��b� Cert.Tester No. �� Date l� � * 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 ariginal 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) MaII,iN�aDDREss: 1303 ��a��er C;�- �P�ell ix �5 01� CONTACT PERSON/PHONE: I�e„u►5 YV�er:.1 u Z 'f-�L -�D�FO LOCATION OF SERVICE: (�6"� � . Q�t�,va.y 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 7Reduced Pressure Principle-Detector C�ouble Check Valve 7 Double Check-Detector �lPressureVacuumBreaker f ISpill-Resistant Pressure Vacuum Breaker / ^� � r► Manufacturer �/a 5 Model Number Dd�7 m�� Size � Located At �Gc%tl ��rf�DSe N. Cl� Serial Number � 8�� Is the assembly installed in accordance with manufacturer recommendations and/ar 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 �� 7 psid Opened at Opened at Held at Initial Test Closed Tightf�C Closed Tight� psid psid psid Leaked�' Leaked 1 Did not open l Did not open ��1 Leakedl 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 l_.OIV�Dr�-O ��-�� ITL SN: ZS G��17 Date Tested for Accuracy: ei/2O/�� Remarks: The above is certified to be true at the time of testing. Firm Name�,9 pQ��l �,� Firm A ddress /.��' �-=1� C/l� � Certified Tester(prsnt) � � Certified Tester(signature) � � � Firm Phone# �1��'/�o-1�oT� Cert. Tester No. � /O� Date � n� * 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 1.D. # 0570040 (Customer) ' \ MAILING ADDRESS: ��03 W IY�i'i'1 PY �i✓' CONTACT PERSON/PHONE: i�S ' LOCATION OF SERVICE: S G7 � �Ltr 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 -]Reduced Pressure Principle 1Reduced Pressure Principle-Detector �oubleCheckValve -1Double Check-Detector �_�PressureVacuumBreaker �Spi11-ResistantPressure Vacuum Breaker �i/ Manufacturer �a� Model Number ��7�� Q7 Size Located At IJ�Y11tn� ��,�,�'t► �Ufe�Se Serial Number �'7 ��04[ 1 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 TightF� Closed Tight � psid psid psid Leakedl 1 LeakedC� Did not open I �'�� Did not open I I Leakedl� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight'��' Closed Tight'�1 psid psid psid Test gauge used:Make/Model�rJracQ �O'znD T�- SN: zs��b Date Tested for Accuracy: � �Zb� (S� Remarks: The above is certified to be true at the time of testing. Firm Name �bppt�� S�Firm Address ��J�3 W �' l�i r �� Certified Tester(pr�nt) 0.V� t � Certified Tester(signature) � Firm Phone# 2�� "�� 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 x 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) , 1 n t �_ MAILING ADDRESS: �3�� W�"=14=c��e: l.-i�✓ �oQ�)1 �� CONTACT PERSON/PHONE: �'S 1"1(�[�Ca�i9.S ZI`-t —1.�.9to—�b4�b LOCATION OF SERVICE: �� . a Cux�,y 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 f_1Reduced Pressure Principle I iReduced Pressure Principle-Detector �ouble Check Valve C 1 Double Check-Detector �1PressureVacuumBreaker �ISpill-Resistant Pressure Vacuum Breaker Manufacturer �Q� Model Number �7 /n 1 �_�Size 2�� Located At Ftp1Y�,��TO�,�m �«�.�k Serial Number �-�-=��3 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�4 psid psid psid Leaked�l Leakedf�'� Did not open I I Did not open I Leaked I��1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight�.] Closed Tight�J psid psid psid Test gauge used:Make/Mode1�,0�'1�1�rCcC.D �0 � 7�C�� `T�N: ZS�� Date Tested for Accuracy: �/ZC��I Sr Remarks: The above is certified to be true at the time of testing. Firm Name��p�� L�� Firm Address �� W �� l i� � � Certified Tester(print) � Certified Tester(signature) � Firm Phone# G� 7 "T�/� —'�Cert.Tester No. 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