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2016_0211 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�e a �C �7SU�N CONTACT PERSON/PHONE: -f �!� `I - 2 - 3S LOCATION OF SERVICE: I � 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 I�Reduced Pressure Principle f Reduced Pressure Principle-Detector !1DoubleCheckValve �ouble Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer W�'�15 Model Number 1 Oq QC�dat Size �� Located At�} S��C�c c1-� �IQq `t� U�c.��- Serial Number I �(9(79 7 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t� 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 _J psid psid psid Leaked�l Leakedf 1 Did not open C� Did not open I 1 Leaked'��'. Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i��i Closed Tight�-1 psid psid psid Test gauge used: Make/Model �,�,��\K�l�S �S SN:�)�( 23d3 � Date Tested for Accuracy: y-�1� Remarks: b� S 1 5 y u M �.� �a 11 A 1��t'S ��l �-t_5� CP�L iC 5 The above is certified to be true at the time of testing. Firm Name.-1-Q eG( �c� Firm Address (9Q/3 l D 1'�y.;�� C�7 r I -�-I��`�«° ,�- c ` -��'�e� Certified Tester(print) I (G(��S l�-c I� Certified Tester(signature � �(Q,(/`�� Firm Phone# �� -aa� -�a�►3 Cert.Tester No.�f��(0�3 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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: d Ke S S�e 3O� ;� �-7 S�l CONTACT PERSON/PHONE: � e `1a— 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 I�R�uced Pressure Principle ❑Reduced Pressure Principle-Detector [►�'DoubleCheckValve ��]Double Check-Detector �PressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker �r Manufacturer��'� Model Number�'Z`7 �`r�� "� Size v� Located At� S j� � 4� A�}�,�,r��T �trSerial Number 4.�10� ( Is the assembly installed in accordance with manufa urer recommendations andlar local codes? e S' Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check � f»� Held at�psid Held at ��oZpsid Opened at Opened at Neld at Initial Test Closed Tight!-_ Closed Tight �_� psid psid psid Leakedl�l Leaked❑ Didnotopen I7 Didnotopen ' I Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight n psid psid psid Test gauge used: Make/Model ��i� \�i(�S � G � SN: O3 i 23U3� Date Tested for Accuracy: y—{.o—1� Remarks: The above is certified to be true at the time of testing. Firm Name �'C.[,Z( -��Q_ Firm A ddress�91.� �D 1�0i,..� Q�� l'!�/1��1�(1� �- . Certified Tester(pr:nt} � fAlirS � �I Certified Tester(signature)��I(11h �� Firm Phone# �j(7�c�^ ��3 Cert.Tester No.{�' P��(y�(3 Date vZ—1 I^�4 * 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) MAILINGADDRESS: � e e � c '�( -�S(xyi CONTACT PERSON/PHONE: -e " a.-a - S LOCATION OF SERVICE: I� ,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 �_ educed Pressure Principle I Reduced Pressure Principle-Detector -Double Check Valve r7 Double Check-Detector �PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer 1..,L�^�-S Model Number (�C)�l M�(�� Size � �i Located At�8��e c�- �1�Q�L.�e��n2 Serial Number q 7�j�(� Is the assembly installed in accordance with manufacturer recommendations 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 �� 5 Held at��psid Held at�psid Opened at Opened at Held at Initial Test Closed TighLi�� Closed Tight H� psid psid psid Leakedf 1 Leakedf�l Did not open I� Did not open :�] Leakedl I � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight!:� Closed Tight I_I psid psid psid Test gauge used: Make/Model f.�,i `��nS '�G� SN: (�)3�2�f).�� Date Tested for Accuracy: y-(P--( � Remarks: The above is certified to be true at the time of testing. FirmName��G � � (�-- Firm Address�9�� _/'�,p �i��`� (�`V� f f� ^'�'-�C.�rC, Y Certified Tester(print) 1��'�f5l�e j�Certified Tester(signature) �/IQL(1� � ,� � Firm Phone# �� -aC�—/��i 3 Cert.Tester No._�Bf��ic((��3 Date o7"�)-/� * 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 r/ 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: t �S ► 7S(�L�1 CONTACT PERSON/PHONE: Q .� 7 -a - ' 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 '��Reduced Pressure Principle-Detector I�'�OubleCheckValve f�'��Double Check-Detector IiPressureVacuumBreaker !. 1Spi11-Resistant Pressure Vacuum Breaker �� Manufacturer (,vR-�TS Model Number (�'� Size � Located At�AS� SF��e��\��UQ�,.�� Serial Number ��5� Is the assembly installed in accordance with manufacturer recommendations 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 � 1 A �� Held at � psid Held at o��d psid Opened at Opened at Held at Initial Test Closed TightCl Closed Tight � psid psid psid Leakedi.l�� Leaked`�l Did not open .�l Did not open I�_I Leaked� l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight'J Closed Tight�� I psid psid psid Test gauge used: Make/Model_Lt,� \�C.��1 S �C�5'r SN: C�3�2303} Date Tested for Accuracy: y-lp-1 f Remarks: Iv�e c -� r��G t e � �� }�e c � The above is certified to be true at the time of testing. �oq� CcM (3c�e Firm Name�QG� �jl�p Firm Address B�uCI �T�(.ci� ��C1Uf f Cv Certified Tester(print)�rGt�,�i5 �Ch�r� Certified Tester(signature)�/�(.�� f��11 _ Firm Phone# Q))��a�- �a�'3 Cert.Tester No.��j(�j c�(,C�3 Date �-)��Ce * 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