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2016_0429 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: LOCATION OF SERVICE: �t , The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is cerrified to be operating within acceptable parameters. TYPE OF ASSEMBLY �'Reduced Pressure Principle � IReduced Pressure Principle-Detector �ouble Check Valve 1Double Check-Detector '�Pressurc Vacuum Breaker I Spill-Resistant Pressure Vacuum Breaker Manufacturer � �LJI�,I.� Model Number �. F�1'�� 1 (� IS�i�e Z� � j I� �� L�oc�d At � � � ' � Serial Number �� (p � �- �� s e asse in accordance with manu acturer recommendations and/or local codes? [��e 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 Leaked I�'� Leaked. I Did not open I 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 I 1 Closed Tight� I psid psid psid Test gauge used: Make/Model L, � ' QY�� S SN: Date Tested for Accuracy: �-' I�- ( Ld Remarks: The above is certified to be true at the time of testing. Firm Name��f 1( ,�/� ��1�(��Address � ��__�� ; ��'`�f� �G�� -�'� Certified Tester(print "��l 9 � ��fied Tester(signature Firm Phone��j�� L�� - ��C�ert.Tester N ��ate '1r — � * 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�� ,�5 The following farm 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: �1�--��- ��C C�l�l CONTACT PERSON/PHONE: ��l��y, ��_ LOCATION OF SERVICE: �� C�� Q h�� 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 �� Double Check-Detector I IPressurcVacuumBreaker ��-Spill-Resistant Pressure Vacuum Breaker Manufacturer W(a-�� Model Number (�(�� Z Size ��-1 Located At �„��, �[�U �,� Serial Number � �� D 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'�(l Closed Tight I' psid psid psid Q�S S� Leakedf 1 Leaked� I Did not open f�'� Did not open �� Leaked��. Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight�1 ClosedTight I psid psid psid i Test gauge used: Make/Model ! � �,�(��S' � �SN: �� Date Tested for Accuracy: I—�— � �' � �n Remarks: The above is certified to be true at the time of testing. FirmName�r�C.� �i�� ('(�� Address 1 �'��1� � �'�"K ��5 Certified Tester(pri � �f � � 'Q�tified Tester(signature) /� ��r.� ��^� Firm Phone�� Y, � �,Z�� Cert.Tester No�� Date � � �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) l MAILING ADDRESS: �VL l`C, CONTACT PERSON/PHONE: I? C�. LOCATION OF SERVTCE: z� 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 V alve ��Double Check-Detector ` 'PressureVacuumBreaker ' Spill-Resistant Pressure Vacuum Breaker Manufacturer Model Number �r 1�(�'��' �� l'� 1 Size � Located At i�✓L3�(� S s ��. , ��( Serial Number �� )e(D.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�psid Held at�psid Opened at Opened at Held at I itial Test Closed Tight� Closed Tight �Q psid psid psid ��r� Leaked'i Leaked' I Did not open I Did not open ' Leaked. Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight I . Closed Tight� I psid psid psid Test gauge used: Make/Model lN � ��(�� SN: ��'��1 � �S Date T�sted for Accuracy: � � � � �- � „ Remarks: The above is certified to be true at the time of testing. Firm Name�MEY�1'�Y1 �� (�C- �r U9t��ddress � fl�7'S �/ �� s�A—�'�' ��pt��'S �� Certified Tester(print ��'� Qti,, [�rtified Tester(signature) Firm Phone#10l��-'� `rt'�� 2 � Cert.Tester No�� o � 1 Date � � �a v * 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 y 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 LD. # 0570040 (Customer) T MAILING ADDRESS: J.J�- � lc L'}' CONTACT PERSON/PHONE: �- ' % LOCATION OF SERVICE: t � 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 � 1 Reduced Pressure Principle-Detector �DoubleCheckValve -'Double Check-Detector I PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer �,�Ll�'�`5 Model Number vv� � � Size � �r Located At�_��'��..fi J�� r Serial Number �� 1� Jn�� (,� 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 � � !). Leakedf '� Leaked l Did not open I Did not open ' Leakedl � Repairs/ Materials � Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight �l ClosedTightl �� psid psid psid f � .�► Test gauge used: Make/Model � ��— 1\. � ��J SN: � � �� Z � � Date Tested for Accuracy: ' �1 ' Remarks: The above is certified to be true at the time of testing. �/� � � Firm Namel�l'�,(CC�t� �Y��1�� Fa�C�Qddress� �� s �'�� -�� 'j�'J'Ty� Certified Tester(print"�1G�.Y�(VI -��j�,��ertified Tester(signature) Firm Phone#� �� ` 1 �� 1 Cert.Tester No Q �� 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 Y 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: CONTACT PERSON/PHONE: C' l� 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 •j�ouble Check Valve �i��Double Check-Detector I Pressurc Vacuum Breaker ' 'Spill-Resistant Pressure Vacuum Breaker � � Manufacturer �(�� S Model Number �Q � �� Size�_ Located At (� �r�C� ��Q�t r Serial Number /�Z �1� t�� 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 I�itia�l Test Closed Tight� Closed Tight '�, psid psid psid Leakedl Leakedl I Did not open ' Did not open I Leaked�� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight I 1 ClosedTight _I psid psid psid Test gauge used: Make/Model ��, ��I_(P�S ��S SN: �.� �� -f (�r� Date Tested for Accuracy: � �- � � -- � �J Remarks: The above is certified to be true at the time of testing. FirmNarr�-t�j,�t� C �� I�Cc�G`i�(�l�l� Address � ��j ��,� �,tA 1T� �(� f' � � I�� T—_ i Certif ed Tester(pri�t �' �� t� C�tified Tester(signature) d Firm Phone#t�,��.h �`"I � " �a�Cert.Tester Nq��'�L� I � �� Date ' � � � l� * 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 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 I.D. #0570040 (Customer) MAILING ADDRESS: 1�.� � � L vfi CONTACT PERSON/PHONE: � LOCATION OF SERVICE: G��- The backflow prevention assembly detailed below has been tested and maintained as required by commission regularions and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY : Reduced Pressure Principle 1 Reduced Pressure Principle-Detector ��Double Check Valve !Double Check-Detector I PressureVacuumBreaker �-:Spill-Resistant Pressure Vacuum Breaker � Manufacturer ��J Model Number_�1J� m�__Size 7i � � Located At�,�n.��f ll. S�� Q ��2��C,r Serial Number A �—�(1� �� Is the assembly installed in accordance with manufacturer recammendations 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 (�G��'j Leakedl�� Leaked'� 1 Did not open �� 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��1 ClosedTight I ' psid psid psid / Test gauge used: Make/Model < l �.� sN: ,�`� � �� r� � Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Firm Nam� ,1'�C� �1�'l.�'4�C�� i r� Address �O�� 1,�IJ � �__�� 1��'�`� �- Certified Tester(prin� �a��ed Tester(signature) �a/Iti (o . � Firm Phone��-'�,��Z, �Cert.Tester No C7 J / Date � '' � ' �CQ * 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�_� ��-S� 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: � G�� ? �, CONTACT PERSON/PHONE: f✓ LOCATION OF SERVICE: D� � ' , 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�ouble Check Valve �Double Check-Detector f PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer ��/,�( �� Model Number �U 7�1 e2� Size �� / Located At ��'I'L- ��,,�►,L 1 � Serial 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 ��V psid Held at �� sid Opened at Opened at Held at I itial Test Closed Tight�l Closed Tight I� � psid psid psid � � Leaked I I Leaked. I Did not open I I Did not open I '� Leaked�� I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opcned at Held at Repair Closed Tight i 1 Closed Tight I I psid psid psid Test gauge used: Make/Model��, l �� Q. � C �l�S SN: �Q `, I')� � � � �S Date Tested far Accuracy: /�-f ' � � + � l� Remarks: The above is certified to be true at the time of testing. Firm Narr�Q C'� �'�� Ci `1 ��1:C�Ir�n�ress�� 'f� ��: �� —�l�f�s Certified Tester(pr��r)1��'�Y' F?�f�,��'�rtified Tester(signature) � #�.��-�7'j �Cert. Tester N�7"C�� ate c �p Firm Phone � � * 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—ti�� DOMESTIC FIRELINE�� l�' 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) ,l . MAILING ADDRESS: ��-1—�— � CONTACT PERSON/PHONE: t7 (J� i,C. 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 � IReduced Pressure Principle-Detector I�ouble Check Valve I Double Check-Detector '�� PressureVacuumBreaker �1Spi11-Resistant Pressure Vacuum Breaker Manufacturer ��S Model Number ' 6��' b C�h �. Size �� Located At j �,� �[►��.�,�� Serial Number � Q Cj"Z2D 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 �r�psid Held at � psid Opened at Opened at Held at �tial Test Closed Tight'� Closed Tig t �1 psid psid psid � � Leakedf � Leaked��1 � Did not open ; Did not open � I Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTightl�� ClosedTight'�� I psid psid psid , \r ) J' Test gauge used: Make/Model U� � l ��1/��+ � � SN: ��Q�� Date Tested for Accuracy: � " � � � � � Remarks: The above is certified to be true at the time of testing. Firm Nam��l'.��1'��r�L\�(,Eli�i��ddress � �� s�Jl� 1�'� � '�-pr 11� S Certified Tester(print} ��r� tified Tester(signature) � � Firm Phone�l�-��. � Cert.Tester No. � 'l� � ��ate � � ' ( � * 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�,(.�ti� �`\v 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: � e - �C>-E— CONTACT PERSON/PHONE: ` ` LOCATION OF SERVICE: � �` The backflow prevention assembly detailed below has been tested and maintained as required by coinmission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ' Reduced Pressure Principle ' Reduced Pressure Principle-Detectar '�I�ouble Check Valve i ��Double Check-Detectar ' Pressure Vacuum Breaker '� Spill-Resistant Pressure Vacuum Breaker Manufacturer I� (��C (, S Model Number��`7' �U /�_Size � � Located At �� 2 n-• �('n G�, �� Serial Number �0�� _�C�'� 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 �e psid Opened at Opened at Held at I�ial Test Closed Tight� Closed Tight� psid psid psid Leaked I Leakedl�' Did not open � Did not open i Leaked� Repairs/ Materials Used Held at psid Held at psid Test After Opencd at Opcned at Held at Repair ClosedTight I I ClosedTight�1 psid psid psid Test gauge used: Make/Model �, � � ��'` � SN: �� `7 2 �� Date Tested for Accuracy: � �� Remarks: The above is certified to be true at the time of testing. Firm Name��Pf��r-�1}'c� `�'�.10 ,�dress � Q J�� V � �� / � �1� ��S Certified Tester(pri nt Q�f f ertified Tester(signature) _ �1�,� Firm Phone#�� ,�Zi�Cert.Tester N ate �— � �� " * 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 LD. # 0570040 (Customer) ,! MAILING ADDRESS: t,L�� C�I "1 � CONTACT PERSON/PHONE: Q �'7 , LOCATION OF SERVICE: The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operaring within acceptable parameters. TYPE OF ASSEMBLY �1Reduced Pressure Principle I 'Reduced Pressure Principle-Detector �DoubleCheckValve I Double Check-Detector � Pressurc Vacuum Breaker i��Spill-Resistant Pressure Vacuum Breaker ,l � /, s�// Manufacturer IM�� Model Number �v ��I � Size Located At (�� Serial Number � �� Ts 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 �a�� psid Held at (�� psid Opened at Opened at Held at In al Test Closed Tigh{� Closed Tight '� psid psid psid ��'S Leaked'� Leaked'' I Did not open Did not open I Leaked Repairs/ Materials Used Held at psid Held at psid Test After Opencd at Opened at Held at Repair ClosedTight-1 ClosedTight I psid psid psid Test gauge used: Make/Model Vv�. ��''U� � SN: �� ? � � � � Date Tested for Accuracy: ��`��"� Remarks: The above is certified to be true at the time of testing. FirmName��`�-��G'I�II� ' l�� 11��`�'irm Address d��5 �/s571� ��C,. 1�`�' Q � Certified Tester(print) �IJai�1�� f?ti � Certified Tester(signature) Firm Phone# �� '�"1� �� Cert.Tester No�` �� Date �� ' l � * 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