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2015_1230 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) 1 e MAILING ADDRESS: � 1 J • �2 I��. �� CONTACT PERSON/PHONE: � 11L��►.� R Z. "ol- C( 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 C]Reduced Pressure Principle ❑R�duced Pressure Principle-Detector ❑Double Check Valve '�Double Check-Detector ❑PressureVacuumBreaker �]Spill-Resistant Pressure Vacuum Breaker �-� �� Size O // Manufacturer H �'eY Model Number Located At �� `''� ��1 Number –t q l U' �Q� 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 Heldata' `pfsi� Held at �' b psid Opened at Opened at FIeld at Initial Test Closed Tightl�l' Closed Tight � psid psid psid Leakedf�I Leakedn Did not open ❑ Did not open I I Leaked�; Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair C]osedTight I J ClosedTight❑ psid psid psid Test gauge used:Make/Model�•cl►W�ti� ��1,� SN: ��)� � �U � � Date Tested for Accuracy: S'��'� � Remarks: The above is certified to be true at the time of testing. FirmName��tC�'�4q+(.2 r�=—=FirmAddress ��a� !'�:'1t 4^��1CL-�� /�i I�4� 7��'Z"U Certified Tester(pr�nt)1�Ifi'�� C�U�-Certified Tester(signature) /�I. � � Firm Phone#� � 1 '�l� I 7��L� Cert.Tester No.��C/�filSTC ��Date �� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-'Fester's Copy IRRIGATION_ /1 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) �1 MAILING ADDRESS: a�- S • 1 f e ��' -n� CONTACT PERSON/PHONE: � Y'to�,�y�, Q- 2 q LOCATION OF SERVICE: �,� 5�� „�_ 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 rlReduced Pressure Principle ❑Reduced Pressure Principle-Detector ��ouble Check Valve ❑Double Check-Detector ��PressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker �11 Manufacturer � G(� Model Number �f�� Size Located At � �T"^ `'S Q `T `�`'�'�—�erial 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 Inirial Test Closed Tight� Closed Tight � psid psid psid Leakedl I Leaked❑ Did not open 17 Did not open CI Leaked�,-� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I�1 Closed Tight�� psid psid psid Test gauge used: Make/Model ��W eti� �� SN: lU� � �G� � Date Tested for Accuracy: �'� �-� � Remarks: The above is certified to be true at the time of testing. Firm Name�"-Fw`"''''��1 tQ �!�'- Firm AddresslU�--`1 G'� �'�� LV•�� ,a.� ',�0. I�� 7� '�ZV Certified Tester(pr,nt)�� Gw�CertifiedTester(signature) �' ''I � Firm Phone# a��( Q C'� ��j.� ( Cert.Tester No.��GU�11'(�U 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: I v� � S . � �� Q, CONTACT PERSON/PHONE: i'naf.� S LOCATION OF SERVICE: ��` 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 1Reduced Pressure Principle ❑Reduced Pressure Principle-Detector L�ouble Check Valve �ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer � e � Model Number '✓ � Size �� Located At V�v 1 � S UV� S.0�'�� Serial Number q r 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 TightC�Y Closed Tight L� psid psid psid Leakedn Leaked❑ Did not open C_l Did not open L� Leaked�l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight G psid psid psid Test gauge used: Make/Modelrn�C/1W'�� t{ � SN: �� U� I Date TestedforAccuracy: S—� � `I � Remarks: The above is certified to be true at the time of testing. FirmName 1_'�('}�"�►1Ancc ri �� Firm Address �G�p�-a �'^S (,�•�l iov�, f � CertifiedTester(pr�nt)�5�� q�X�CertifiedTester(signature) �1• � Firm Phone#_oZ_�_�( �� 7 r1,�� Cert.Tester No. ��'il�ItZ'� CJ 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: CONTACT PERSON/PHONE: �' ��'ru a„ .Z LOCATION OF SERVICE: � 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 I__iRe ced Pressure Principle ❑Reduced Pressure Principle-Detector C ouble Check Valve �Double Check-Detector ,-I Pressure VacuumBreaker ��I Spill-Resistant Pressure Vacuum Breaker Manufacturer �r"�� Model Number Size �� Located At 1) � �2�'Q•'r �jQ,`�'�"°`Se ial Number � �u'�'� �'�(`�,/ 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 �' � psi Held at�psi Opened at Opened at Held at Initial Test Closed Tight'�_ Closed Tight C psid psid psid Leaked'�-1 Leaked❑ Did not open Ll Did not open [I Leaked� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight'�� Closed Tight❑ psid psid psid Test gauge used: Make/Model �'v,W e S� �� SN: �O�� V r� Date Tested for Accuracy: S'� 3 -� � Remarks: The above is certified to be true at the time of testing. �'e- 4,-�1 �� Lz� FirmName �T�Tr,r'1►�qrlc,e r�' Firm Address ��1 ��'�\ IGn �a 4S Certified Tester(pr�nt�0��►��,� �c.�c�fr.�Certified Tester(signature) I"I. � Firm Phone#�� ►�� 'r1�+� Cert.Tester No.�1�UUl�-S T"U Date * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS 1 �~ �v"� 1 **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) I�� 1 � I �e �� 1' MAILING ADDRESS: � CONTACT PERSON/PHONE: � ��ri "� cJ � �6'� LOCATION OF SERVICE: , �,�, '� � I..-..� 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 �ouble Check Valve C]Double Check-Detector 1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �� Model Number GU � � � Size � �� Located At �� o"''�c- « �"�'��erial 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 �'Z psid Opened at Opened at Held at Initial Test Closed TightC� Closed Tight ��Y psid psid psid Leaked�l Leaked�,� Did not open �.7 Did not open �:-I Leaked�l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight f_1 Closed Tight� psid psid psid Test gauge used: Make/Model �'1�,� u,�� t � SN: 1� � � �U �� Date Tested for Accuracy: �� Z�� Remarks: The above is certified to be true at the time of testing. Firm Name p�f'T�'YhA�..� t•'�'C Firm A ddress��/�c�-�1, L�''i-S `�•�� h'i/�G� 7 T�Z U Certified Tester(pr�nt)�flS�� ►U✓�Certified Tester(signature) /�I• �(,PI� � Firm Phone#�l��1�Q 1 Cert.Tester No.��v Date I tl. - �(J�t 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