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RPZ_2015_0226 IRRIGATION DOMESTIC �C 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) � �I��,S MAILING ADDRESS: �� QYI �►1 CONTACT PERSON/PHONE: i vl� � s ,g�y, pj�� 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 4�educed Pressure Principle I� iReduced Pressure Principle-Detector i- Double Check Valve I Double Check-Detectar ' IPressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer 1/Ull� 5 Model Number � /�oZ QT Size�_._ Located At � �S� '1/lleC�Iplyt,tCc� ra-on1 Serial Number R��a�� 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� I Closed Tight I psid psid psid Leakedf�'�� Leaked��l Did not open I Did not open f I Leaked'�� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight�� 1 ClosedTight �l psid psid psid Test gauge used: Make/Model SN: Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Firm Name Firm Address Certified Tester(print) Certified Tester(signature) 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 K FIRELINE The following fortn 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) 11�1�5 MAILING ADDRESS: �� C�,2nyc�►� CONTACT PERSON/PHONE: 'Ti✓bt '�-t��pvs1�=.� 6 f-9G�/ �/SS— 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 �uced Pressure Principle �iReduced Pressure Principle-Detector i-'Double Check Valve -1 Double Check-Detector �PressureVacuumBreaker � Spill-Resistant Pressure Vacuum Breaker Manufacturer ��t5 Model Number �0� �� Size� Located At Uy1�Qr '�j�� IV� brCR�-rl��1�1 Serial Number �nOo�� 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''� I Closed Tight '�1 psid psid psid Leakedr''� Leakedl ' Did not open I I Did not open � '� Leaked� I Repairs/ i ��e rC ple�,ce re p ac�/� Materials � /� c(�Ck � � C�CF re�ie t' Used �,�,C,� Held at �� psid Held at�psid p a, Opened at Held at Test After O ened at 3� Repair Closed Tight_� Closed Tight � psid psid psid Test gauge used: Make/Model �I�.KI IJ S �G`� SN: D3 J l a�9�+ Date Tested for Accuracy: �}- �- -20 i S Remarks: The above is certified to be true at the time of testing. FirmName �� pcha►u�al Firm Addressa� � �I�IQV'G� -�t• l�r�Lcr '� Certified Tester(pr:nt)� � �' Certified Tester(si ature Firm Phone# ��'�34'/��D Cert.Tester No.B� �D/�iG3� Date �-aG�3v/Si * 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) /NE MAILING ADDRESS: �Sb p CONTACT PERSON/PHONE: - vS � � - /B,SJ 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 i�Keduced Pressure Principle -'Reduced Pressure Principle-Detector � :'DoubleCheckValve ' 1Double Check-Detector ' IPressureVacuumBreaker Spi11-Resistant Pressure Vacuum Breaker Manufacturer��jr Model Number �9 /j13 f�r Size 3l�- Located At 1 �c� I�IPP�'V]N,I�A� �-pflyy� 0/1 `ffTA Serial Number�9 ��-� Is the assembly installed in accardance 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 `a•tP psid Held at �•�P psid Opened at l�� Opened at Held at Initial Test Closed Tighti✓ Closed Tight '�"� psid psid psid Leaked'�I Leaked' I Did not open � ; Did not open I I Leaked�� Repairs/ � �ud r� C 1�t-��l.LL Materials � � n1�,_k � � � r,�,l(�,� �� Used ��`�'�' � Held at $•a psid Held at �f� psid Test After Opened at �a- Opened at Held at Repair Closed Tight I� ClosedTight'�"I� psid psid psid Test gauge used: Make/Model �,�L,�,\�S ��- S� SN: �.�/1�� Date Tested for Accuracy: � - � � 20 l� Remarks: The above is certified to be true at the time of testing. �ech��,�a,� �S � � � - � FirmName I� Firm Address �'�[ �, Q� a�r � � Certified Tester(print), �n � Certified Tester(sign ure Firm Phone# ��'J�.��'lal� Cert.Tester No._ ��p�p 3� Date ,��(o ��fJ/� * 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: ITY OF COPPELL PWS I.D. #0570040 (Customer) �IrU�5 MAILING ADDRESS: SD CONTACT PERSON/PHONE: ''i�wl � - �/- $ 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 I�duced Pressure Principle JReduced Pressure Principle-Detector iDoubleCheckValve IDouble Check-Detectar 7PressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker Manufacturer �,�5 Model Number �q �3 Q� Size �/� Located At l �5� INl �C4,� flhnt B'YI ��►�`Serial Number ��708'� Is the assembly installed in accardance with manufacturer recommendations and/or local codes? f� 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 9�� psid Held at ��— psid Opened at l,� Opened at Held at Initial Test Closed Tightf'1� Closed Tight I� psid psid psid Leaked� 1 Leaked�I Did not open I Did not open I��' Leaked � Repairs/ �'(��d N(�ttC� �''�� Materials ,�� ,h,�t� j�� .K- /^�� r`f Used Held at��_psid Held at�_._�{psid Test After Opened at 3 (P Opened at Held at Repair ClosedTight � ClosedTight.� psid psid psid Test gauge used: Make/Model �'v�I Cl�Yl s �� SN: C>3�1�`�� Date Tested for Accuracy: ___ _'�}��' '��-s Remarks: The above is certified to be true at the time of testing. Firm Name ��11� �QLYIQV�C Q�� Firm Address r� (� c�T, /'�e�,-� ��/ Certified Tester(print)� �:1 Certified Tester(sign re) � Firm Phone# ��+' �� '1 y� Cert.Tester No. 9�8�� .3/ Date �d�(p f�D/�� * 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