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2016_0323 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 1.D. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: , �1 f v 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 �lj�educed Pressure Principle Reduced Pressure Principle-Detector ��Double Check Valve C��Double Check-Detectar ��PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker �✓ y�� Manufacturer �i�'✓''f� Model Number /�' a Size Located At yl�iaTs J.�O�k /�✓H� /C�3 t'� �� 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 Z��psid Held at �•Zpsid Opened at Opened at Held at In' ' 1 Test Closed Tightf� Closed Tight I✓ psid psid psid �� Leaked.�1 Leakedf' Did not open '� I Did not open I� �� Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight'�_] Closed Tight��l psid psid psid Test gauge used: Make/Model ��L�/lQ /%/�-5-U SN: Q��0.2 3 7y Date Tested for Accuracy: y'��' ��✓~ Remarks: The above is certified to be true at the time of testing. FirmName��- ��,fT'fi��, r�'r. Firm Address 7v�/ �0�� /t�li�J�'�i✓ � Certified Tester(prf nt) ' i/A� �Y'1ti Certified Tester(signature) Firtn Phone# ��/j;� �yf?'�Z�✓� Cert.Tester No. ,��j/�� Date � ��.3� 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 for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping purposes: BACK�LOW 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: • �� a �,�' 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 i R duced Pressure Principle :1Reduced Pressure Principle-Detector '��oubleCheckValve -'Double Check-Detector ' 1Pressure Vacuum Breaker � Spill-Resistant Pressure Vacuum Breaker Manufacturer �� f� Model Number /Y�• �- Size < Located At //�,'�3 f� �J� Serial Number �v f `�� y 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 Z°� psid Held at ��Z psid Opened at Opened at Held at I ' ial Test Closed Tight�Y Closed Tight � psid psid psid �y�! Leakedl � Leaked'� I Did not open �� Did not open � 1 Leaked i Repairs/ Materials Used tp Held at psid Held at psid Test After � Opened at Opened at Held at Repair Closed Tight CJ Closed Tight� I psid psid � psid Test gauge used: Make/Model f/�P�(O /�i�✓�f� SN: � �� 1-3 7�/ Date Tested for Accuracy: �—�� -- �d l.� Remarks: The above is certified to be true at the rime of testing. Firm Name�� `� ✓��.�7��1, �/�'G- Firm Address 7-�� Q9r� /�tr�/�r/��''vf � Certified Tester(�rint) UI/A� KTl�i Certified Tester(signature) Firm Phone# ��17, `a yl�`"�'Z�3 Cert.Tester No. .��3f�'d Date �-z3" 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 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: CONTACT PERSON/PHONE: LOCATION OF SERVICE: :S� � � F�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 CReduced Pressure Principle-Detector �-�oubleCheckValve C'��Double Check-Detector '�=7PressureVacuumBreaker � '��1Spill-ResistantPressure Vacuum Breaker Manufacturer �� fJ`� Model Number �0r1� � S Size ��d Located At L��J��/ry .!Jpc,� -��f /�i_Sf.t'• � � Serial Number � 7� ,3 �� Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? � �j 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 Ini ' 1 Test Closed Tightf-� Closed Tight f-� psid psid psid � g'� Leakedf�1 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 ClosedTight f ClosedTight f I psid psid psid Test gauge used: Make/Model ��'�� ,�/�`.� �� SN: ��..� �� Date Tested for Accuracy: 9' �a �o� �� Remarks: The above is certified to be true at the time of testing. FirmName�'f�e`� ��f�'1�, �'�C Firm Address 7�/ �a�p� �l� 7a� � Certified Tester(pr�nt) ' v a� ��">� Certified Tester(signature) Firm Phone# GY/7� Ga%�- Z Z�.3 Cert.Tester No.,��1.3/lGl� Date :�'�3�L�a� * 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 v 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 MA�NTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS 1.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 certified to be operating within acceptable parameters. TYPE OF ASSEMBLY I_ Reduced Pressure Principle -,Reduced Pressure Principle-Detector �ouble Check Valve ��Double Check-Detector �PressureVacuumBreaker ' ISpill-Resistant Pressure Vacuum Breaker i/f/ Manufacturer fz�/�/.S Model Number ;��J� /� Size 5' Located At ��.j �i�'�19 Serial Number (�� is the assembly installed in accordance with manufacturer recommendations and/or local codes? 1 J 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 '�' �psi Opened at Opened at Held at Initial Test Closed Tightl�� Closed Tight psid psid psid ��r Leaked� I Leakedf'� Did not open � I 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 I ClosedTight I psid psid psid Test gauge used: Make/Model /7�Cf//Q — �/�� sN: ��l/�3 7 y" Date Tested for Accuracy•.� �T/�� _ Remarks: ��-�%� "� �-��.S The above is certified to be true at the time of testing. Firm Name �� .�Y�� -�NL- Firm Address l3 � ��.�r �N� �t}�✓ T� 7l�n/I Certifred Tester(pr;nt) �fJ/�� +'tT�� Certified Tester(signature) � Firm Phone# ��" �y� �Z z-3 Cert.Tester No. B�C�Df�/ Date ,�� 3"f� * 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 p�iblic water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: �/ f.�' . �T �' Ll.� rS 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 -lI�educed Pressure Principle I JReduced Pressure Principle-Detector ��oubleCheckValve ��1Double Check-Detectar IPressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer /9'� t-� Model Number �� Size 7�� Located At L p�.��/�/�/ ✓�C�` �7 Serial Number !Q/� �� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? P,J 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� psid Held at Z'9psid Opened at Opened at� � Held at �Im ial Test Closed Tight�� Closed Tight -'I� psid psid psid jq-SS Leakedl Leaked' 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 ! ClosedTightl � psid psid psid Test gauge used: Make/Model��O/� ��/��l� sN: D 9� y�3 7y Date Tested for Accuracy: 7'" J� " Zv l.� Remarks: The above is certified to be true at the time of testing. Firm Name U,��' ��f�f: �r. Firm Address 73I /��7�� /��rl�fTla� �� Certified Tester(print) �fA��T� Certified Tester(signature) Firm Phone# C�f�J��Q" �Z'�� Cert.Tester No.;�PUU/3/ D Date -3�� f� * 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 LD. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: I � ��l � i�,.3 /�,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 ��R duced Pressure Principle CReduced Pressure Principle-Detector ��ouble Check Valve �iDouble Check-Detector !PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �I G��..S Model Number �O�' L� Size � �/ Located At �/� l� � ��k ��jP/�/.� Serial Number /f a D ��' O� Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? ' �.J 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 Ini ial Test Closed Tight� Closed Tight � psid psid psid �.�s� Leakedl�� 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 � Closed Tight�'� I psid psid psid Test gauge used: Make/Model ��//C/ �%/E`.Sl✓ sN: a �i 5� �3 �� Date Tested far Accuracy: �- l"� ' a d�•� Remarks: The above is certified to be true at the time of testing. FirmName�L� ��,ST�/Ylf, T.�� Firm Address 7�I �q1��Y � ro� � Certified Tester(pr:nt) �i1�� /�7'1'V Certified Tester(signature) Firm Phone# (�/1�G��" ��Z✓`' Cert. Tester No.�B,�Pa/.�I aQ Date �'Z;3— �6 * 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 1.D. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: / � 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 I duced Pressure Principle �Reduced Pressure Principle-Detector ��ouble Check Valve -7 Double Check-Detector C:PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker ��/ /Q'�• � Size 7 „ Manufacturer ��.5�'� Model Number Located At /t"�l�. �� /t �.Sf� � o� Serial Number O �� 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 Z'J psid Held at c�'� psid Opened at Opened at Held at �In al Test Closed Tight��` Closed Tight I� psid psid � psid �r� Leakedl I Leaked I 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 ClosedTightl ClosedTight'. I psid psid psid Test gauge used: Make/Model /`/��/ /T/�✓r!� SN: � / �y ��3 �� Date Tested for Accuracy: 9� i(� ~� �p%� Remarks: The above is certified to be true at the time of testing. FirmName AC- ��.,'��f�.� � .�.��. Firm Address� r�9��s� ��r-v,�'N�; � Certified Tester(print) U�"�✓ �"��z Certified Tester(signature) Firm Phone# �,8'�� d� � � �� Cert. Tester No. �,t�0�/��I� 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