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2016_0119 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) MAILING ADDRESS: 7 7D �� L�'�'1 � CONTACT PERSON/PHONE: �" 19 V e�-�-�, f � � t — � �! � — l 70 y LOCATION OF SERVICE: 5.!d�- C 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 I I Reduced Pressure Principle `�I Reduced Pressure Principle-Detector �ouble Check Valve -1 Double Check-Detector �1PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �� Model Number ��'�� Size �� Located At �- �� Serial Number Is the assembly installed in accordance with manufacturer recommendarions 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 1 psid psid psid Leakedf�'� Leakedl '� Did not open I 1 Did not open .�I Leakedl l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i�' Closed Tight'i I psid psid psid 4'�/.. Test gauge used: Make/Model C��d �='`�d SN: �G� �l 7�' Date Tested for Accuracy: 3 - � �-�� Remarks: The above is certified to be true at the time of testing. Firm Name �C��n` �� Firm Address �� Certified Tester(�ir�nt) �� /�� SCertified Tester(signature) � Firm Phone# D�� 'sf� °Z�g� Cert.Tester No. l3��°�° ��'Z Date l r�� * 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: 7 7� ��e �'� CONTACT PERSON/PHONE: /9v �'�-fU s G �f— Y��' - 7D �/ LOCATION OF SERVICE: 5✓� � 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 paraineters. TYPE OF ASSEMBLY �Reduced Pressure Principle �Reduced Pressure Principle-Detectar �Double Check Valve �-Double Check-Detector -]PressureVacuumBreaker '-Spi11-Resistant Pressure Vacuum Breaker i� Manufacturer w/�- � �5 Model Number � � 7 Size 3 w��-�ho�s z / Located At �e�"��e�� `- /�o�'�� Serial Number � a 7 � 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�° �� sid Held at a'�psid Opened at Opened at HeLd at Initia]Test Closed Tight74 Closed Tight � psid psid psid Leaked_ 1 Leaked'. 1 Did not open I I Did not open ��I Leakedi I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight[1 ClosedTight[I psid psid psid Test gauge used: Make/Model CO'�" �� y/�� SN: � L' D �f 7`1��i Date Tested for Accuracy: y �� ~�/ Remarks: The above is certified to be true at the time of testing. Firm Name �G�� Firm Address � ` �" �� X�� Certified Tester(pr:nt) �`�t ��Certified Tester(signature) " �'�0 - 5��_ �a�� /�j/�0000lo%z l-i -�'i-/� Firm Phone# Cert.Tester No. 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 ,�C 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) i MAILING ADDRESS: 7 7� ��T� u-/4 � CONTACT PERSON/PHONE: ��R �/ � �( - � l "' y�Q � 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 I 1Reduced Pressure Principle-Detector ��-:�Double Check Valve �ouble Check-Detector � GPressureVacuumBreaker :-1Spi11-Resistant Pressure Vacuum Breaker C /� Manufacturer �� S Model Number �� Size Located At ��- ��t'/ � Serial Number �� 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 Tnlet Check Valve 1 st Check 2nd Check Held at �`� psid Held at�`�psid Opened at Opened at Held at lnitial Test Closed Tight°I� Closed Tight � psid psid psid Leakedl ''� Leakedl-'� Did not open � I Did not open I 1 Leaked� '� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight'� 1 Closed Tight��.I psid psid psid Test gauge used: Make/Model �� `��`� ��''�� SN: 0 � � y�7�� Date Tested for Accuracy: � � �l� Remarks: The above is certified to be true at the time of testing. Firm Name ��" �� Firm Address �� v X �� X/�- �j�� Certified Tester(pr:nt) �� '�1 Certified Tester(signature) Firm Phone# � a� �Sa �� Cert.Tester No.��d��v7�} Date ��l Y-�� * 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: 7 �� u'�� CONTACT PERSON/PHONE: �'" I9 U'c?rc �-�i s — �( � — � 7 0 � LOCATION OF SERVICE: S�J� � 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 �SDouble Check Valve C Double Check-Detector �Pressure VacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker /' / /� Manufacturer �v� � s Model Number C"i U 1� � Size � Located At � �t e� �� ' U��'f'L Serial Number 3 � � � � Is the assembly installed in accardance with manufacturer recommendations and/or local codes? y�� 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 a"� psid Held at �"�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight '��'( psid psid psid Leakedl '� Leakedi I Did not open f 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�1 Closed Tight.� psid psid psid Test gauge used: Make/Model �a�'��o �� SN: � � p Lll7�� Date Tested for Accuracy: 3-� l S Remarks: The above is certifie to be true at the time of testing. C,�/�!i� �!/i C FirmName 5 Firm Address ��' l3�� 7 ��x� ` /�l �Z t f.�/ �/�.�a 5 ��/l Certified Tester(print) � ` Certified Tester(signature) Firm Phone# �0 d �-SS� �'�'7`�l� Cert.Tester No. i3�D��r o�d� Date f—�� `G * 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 IRRJGATION DOMESTIC FIRELINE � The following form must be campleted for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeepin�purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: �7� ��e �'� CONTAC'1"PERSON/PHONE: i9 L e� �; s � �- — O LOCATtON �F SERVICE: 5�� Y The backtlaw prevention assembly detailed below has been tested and maintai�ied as required by commissian regulations aad is certitied to be operating vrrithin acc;eptable parameters. TYPE(3F'ASSEMBLY i.=iReduced Pressure Principle ^iReduced Pressure Principle-Detector ��JDoubleCheekValve t�ouble Check-Detector ^]PressureVacuumBreaker 'Spill-Resistant Pressure Vacuum Breaker Manufacturer W /� f�S Model Nurnber �f� � Size� Located At � . ��V f� Serial Number ��S f y'� ls the assembly installed in accordance with manufacturer recommendations and/or local codes?�F� Reduced Fressure Princi le Assembl Pressure Vacuum Breaker Dauble 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� Closed Tight)� psid psid psid Leaked'` i Leakedr l Did not open ' Did not open ; I.eaked ', Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight�_i ClosedTi�ht 1 ps�d psid �sid Test gauge used: Make/Model C��'�<� ��'�U SN: � � � yl��`� Date Tested for Accuracy: � - � �l� Remarks: The above is certified to be true at the time of testing. Firm Narne �e r�U� �`��-� Firm Address �� -��"y� �� 7 !�"�%�.C%�• CertifiedTester rint �� P ) / ` `'"� � ��ertified Tester(signanir�.)� � Fircn Phone# �d B"�.5�� Cert.Tester No. �3�� Date �—/� �� *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER`S REPLACEMENT PARTS White-City Copy Y�ellow-Customer Copy Pink-Tester's Copy iRR�GATION DOMESTIC FIRELINE_� 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: '� �� ,��e u�� CONTACT I'ERSON/PHONE: I31/e n. f,l i � — – 7 p C. LOCATIl7N OF SERVICE; 5�3 vu The backft4w prevention assembiy detailed below has been tested and maintained as required by cammission reguiations and is certified w be aperating w'rthin zcceptable pararneters. TYPE OF ASSEIV�BLY :-iReduced Pressure Principle �?Reduced Pressure Principle-Detectar �oubleCheckValve -�Double Check-Detector :7PressureVacLiurnBreaker Spi11-Resistant Pressure Vacuum Breaker Manufacturer �� j Model Number_ � � 7� � Size 3/y Located At �/"-- �� Serial Number 3 B � �o Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y �'� Reduced Pressure Prinei le Assembl Pressure Vacuum Breaker Double Gheck Valve Assambly Relief Valve Air Tnlet 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 Leakedf I Leaked❑ Did not open �; Did not ope�� Leaked��: Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Hetd at R�p,�u Closed Tight�' Closed Tight I�a psid pgid �s�� Test�auge used: Make/Model �v� �K�<o % ��" � G o Y/ 7 Y ?e SN: Date Tested for Accuracy: 3� � "�S� Remarks: The above is cenified to be true at the time of testing. � Firm Name //G��U{� �/ �`Z �- Firm Address � Q-�� 7� 7 //��1C12 Certified TesCer(print) �i`C ��d�� Certifi�d Tester(signatur �� Firm Phone# SOO � .j��a'�� Cert.Tester Ivo. I��DQOo7�� /�� — 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