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2015_1230 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: I � c� � S • � � I"'�� >�� CONTACT PERSON/PHONE: � � 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 �R�ed ced Pressure Principle ❑Reduced Pressure Principle-Detector ��oubleCheckValve ❑Double Check-Detector �'PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �� S Model Number (�V�r'' \ Size ��_ Located At �i 1� r�tnac- Vo�� 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��psi Held at � • �'psid Opened at Opened at Held at P Initial Test Closed Tight Closed Tight I � psid psid psid Leakedl 1 Leaked�l Did not open C 1 Did not open ❑ Leakedl �i Repairs/ Materials Used Held at psid I-�eld at psid Test After Opened at Opened at Held at Repair ClosedTight I�`�� Closed Tight C'� psid psid psid Test gauge used: Make/Model r'1•��v�� l�� sN: l Ui 3 l� r �( Date Tested for Accuracy: �—I �"� � Remarks: The above is certified to be true at the time of testing. FirmName��r �W1ce, 1=�� Firm Address �U� �-�1 �''�� c�.-Cl�ov� ��I�l 7 � L� Certified Tester(pr��t)1"�� 1'�cr�►u.v�Eertified Tester(signature) �' �� Firm Phone#0��`I 9 S� 7�Q� Cert.Tester No.d��[ti��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) 1 MAILING ADDRESS: � � � S • 7� I CONTACT PERSON/PHONE: "� �j, 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 f iRed ed Pressure Principle-Detector �Double Check Valve ouble Check-Detector f 1PressureVacuumBreaker C ISpill-Resistant Pressure Vacuum Breaker Manufacturer n �" `�� Model Number C v`� �� l�, V � 1� Size Located At�� ,W'Y�� (/ow C�� Serial Number � � G ` � � 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 �' psid psid psid Leakedl I Leaked[.1 Did not open f l Did not open C Leaked' 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I I Closed Tight❑ psid psid psid Test gauge used: Make/Model �•��5� �� SN: �vi 3�v14 Date Tested for Accuracy: S'� �'�S Remarks: The above is certified to be true at the time of testing. FirmName��'�'rhahcq, r-•�'e-- Firm Address�U�� G�'�G 1... ��,4.h � �0. 1�45 � ��'ZU CertifiedTester(pr�nt)�4�1�� 17'1[.��,y�o�CertifiedTester(signature) 1�'� � � Firm Phone# o� �y �`1,C� �a�� Cert.Tester No.�hU!�ti�'C�V Date ��.� �� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-Ciry 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) 1 MAILING ADDRESS: � � c).,� S, �2 �'�'I�_ � CONTACT PERSON/PHONE: LOCATION OF SERVICE: _� 1 � 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 JReduced Pressure Principle �Reduced Pressure Principle-Detector '�uble Check V alve �Double Check-Detector f 7PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker 1;� Manufacturer ��" � Model Number ��'"� �'� Size � Located At__ _ \� rn,ti �C" C`� n1�.Q,� Serial Number S�4�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 '" �psi Held at I'� psid Opened at Opened at Held at Initial Test Closed Tighti� Closed Tight _ psid psid psid Leaked��. Leaked❑ Did not open ❑ Did not open f:l Leaked��l Repairs/ Materials Used Held at psid Held at psid Test After � Opened at Opened at Held at Repair Closed Tight I�1 Closed Tight�I psid psid psid Test gauge used:Make/Model M•d w-Q�� 1� SN: �U��U� �( Date Tested for Accuracy: S'� �–� � Remarks: The above is certified to be true at the time of testing. Firm Name 1�1-1 �n'�'�'� r�— Firm Address �U� d'� � ��C G"l I1��S �Ituf 7 S L� Certified Tester(pr�nt)�NS� �� tiCertified Tester(signature)�• �t�, i � Firm Phone#� �� a r� ��tQ� Cert.Tester No.��'i�Vl��'U Date I * 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) n� � / MAILING ADDRESS: I ��-1 S 1� I��'"�• '�l CONTACT PERSON/PHONE: LOCATION OF SERVICE: ld- � 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 ❑Re uced Pressure Principle C�Reduced Pressure Principle-Detector � ouble Check Valve C]Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer L`�'a�S Model Number CU� Y'"� Size� Located At (:� � � ' � 1'hQ�� Serial Number �� Y�'S t• y� 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 f- Zpsid Held at�psi � Opened at Opened at Held at Initial Test Closed Tight��: Closed Tighf �� psid psid psid Leaked��`I Leaked❑ Did not open ��7 Did not open ��l 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 1 psid psid psid Test gauge used: Make/Model �• � w'Q� 1 � `1,�/ SN: �U I� �U� y Date Tested for Accuracy: rj— ��'� � Remarks: The above is certified to be true at the time of testing. Firm Name Q�"'�'t'�'1�I�Gv�� 1—'�� Firm Address ��U��. � d'� .►�;; (�v-(,��Gvr �O� ��45 � �� Certified Tester(pr�nt) ��a�� •tified Tester(signature) �- � — � `a 3G-I � Firm Phone# ��y �� Q� 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