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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 LD. # 0570040 (Customer) MAILING ADDRESS: S�f�n9� [� 5� 3CU �r-� ;5(Y1 �( �75Cz�1 CONTACT PERSON/PHONE: �-Iqruerl '$Z.l��L�(u 9'�„1_ �ga� 35 ` LOCATION OF SERVICE: 1 11 l.� �na�el 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 ��1R duced Pressure Principle -1Reduced Pressure Principle-Detectar ouble Check Valve ��Double Check-Detector GPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer (�JIATTS Model Number C�`7 (Y13 c�T _Size 3 y �� Located At YO��S�I.�S Cp�-�e� (�� Lc�lLe��[�C� Serial Number A o� � � �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 psid Held at psid Opened at Opened at Held at Initial Test Closed Tightn Closed Tight C� psid psid psid Leaked��.1 Leaked�:I Did not open f I Did not open f '�� Leaked'.1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight rl psid psid psid ✓ Test gauge used: Make/Mode1��P\k-�l\S �TC�S sN:Q 3 t a 3a31 Date Tested for Accuracy: y-�-I� Remarks:L_�l�ib� "�o �eS� A�i��q-le f � -�.5�`�c i�S � 2 Car�C� if � �rec� � The above is certified o be true at the time of testing. Firm Name�p�� '►t Q- Firm Address (s�413 �mp�;,C- 'Q�lt�. �Ti l�Ul� �7(fll ILst Certified Tester(pr:nt)�GIU�s -Ec�e� Certified Tester(signature}�i�ij,o �� Firm Phone#��-�az�:-I��_Cert.Tester No.(3�1�(9�(,3 Date o�-�1-1(Q * 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 I 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: (�s" �� "��1S6�1I 6,)'l �6b� CONTACT PERSON/PHONE: l4�1� <�S E7" LOCATION OF SERVICE: -�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 ❑Re ed Pressure Principle ❑Reduced Pressure Principle-Detector ouble Check Valve C�Double Check-Detectar 1PressureVacuumBreaker ��1Spi11-Resistant Pressure Vacuum Breaker LJ� 3 ►� Manufacturer � �`(�J Model Number �� Size�� Located At '��N�W'�'U'Uly�Q1�G�� Serial Number � 0��115 Is the assembly installed in accordance with manufacturer recommendations and/or 1oca1 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 Held at �� psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tighti- Closed Tight � psid psid psid Leaked�l Leaked�! Did not open CI 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 ClosedTight❑ psid psid psid Test gauge used: Make/Model VI.�� 5 � SN: ��d�`�"`-'� Date Tested for Accuracy: �� /� Remarks: The above is certified to be true at the time of testing. FirmName ��r��'�n � �� Firm Address �� ~ � Certified Tester(pr?nt)UGTrfi (�S Certified Tester(signature �� Firm Phone#��7��`1��3 Cert.Tester No.��d� Date � � f�P * 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: s� �!�- �� I�St�t.I /x �0� CONTACT PERSON/PHONE: � / �c� 'd d' �5 LOCATION OF SERVICE: G� 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 �le Check-Detector -1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker 1� � g „ Manufacturer � � Model Number L 6 g � � Size Located At �(A(d�'� SW�� Serial Number 1 `�''7'T� 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 L 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�1 LeakedC� Did not open ��l Did not open ❑ Leakedl l 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 �1.41 `-"�AO � SN: �3��5� Date Tested for Accuracy: �� Remarks: The above is certified to be true at the time of testing. FirmName�! ��d��(,f Firm Address �l�� l�k��►fR�! 7(��b Certified Tester(print� t��`6�-�� Certified Tester(signature) Firm Phone# ��7`��D�� Cert.Tester No. �%�Z��O" Date Ss'��! * 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