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2016_0413 IRRIGATION DOMESTIC FIRELINE�C 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) MAILING ADDRESS: ZI��-I ` / Q 7 C/ CONTACT PERSON/PHONE: - 4g- 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 operating within acceptable parameters. TYPE OF ASSEMBLY Reduced Pressure Principle Reduced Pressure Principle-Detector i �Double Check Valve h/Double Check-Detector ��1PressurcVacuumBreaker �� ISpill-Resistant Pressure Vacuum Breaker Manufacturer WatTS Model Number �]7y��/�A Size �� Located At �i�s� (/u,��i.,�rc�T�� Cw� Serial Number /d g�]Q1-/ 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 1 st Check 2nd Check Held at�psid Held at�psid Opened at Opened at Held at Inirial Test Closed Tight�' Closed Tight �Q' psid psid psid 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 ClosedTightl I ClosedTight I psid psid psid Test gauge used: Make/Model SN; Q,�Q(�Q��iQ Date Tested for Accuracy: -/� - Remarks: The above is certified to be true at the time of testing. Firm Name �}�� Firm Address �Qjf 7j� }�s��, ��a✓,� � .��,��s� T.� 7Sa�g Certified Tester(pri�t) � � � � �� yv� O:�Certified Tester(signature) Firm Phone#��y- �,y�-��Cert. Tester No. �j�QQ/�6�� Date �- �'� -�O/�j * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS Wl}i�e-Ciry Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE� The following farm must be completed for each assembly tested. A signed and dated original must be submitted to the public water supp]ier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: _/y�LJ/ /� `��5 %�/�,,,,,. �'/Q�� [�o,//s TX 75�5y CONTACT PERSON/PHONE: a � 7 LOCATION OF SERVICE: 7O(� f.'✓ /3e� �I iP�. 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 ' 1Reduced Pressure Principle-Detector �ouble Check Valve 1 Double Check-Detector 1PressurcVacuumBreaker �-1Spill-Resistant Pressure Vacuum Breaker Manufacturer V1/��t5 Model Number QQ� Size 3�4 �� Located At ��5� V�u�� y, Serial Number (�h�'�awvi Is the assembly installed in accordance with manufacturer recommendations andlor local codes? �5 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 Inirial Test Closed Tightl � Closed Tight ��I psid psid psid Leaked}� Leaked,� 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 Closed Tight'� Closed Tight�1 psid psid psid Test gauge used: Make/Model Ar��o SN: 0,3�(?��6� Date Tested for Accuracy: -/�- Remarks: � � " 1�'V/ The above is certified to be true at the time of testing. FirmName �{��j Firm Address �QS�� Vs��i ��✓�c�. ��i.; � �J�o�,3g Certified Tester(pr��r) ;�Certified Tester(signature) Firm Phone#�'/�I-3�/C/-,?��I Cert.Tester No. i3/��DI�6/.3 Date y-/,j -�(1�� * 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: a� / CONTACT PERSON/PHONE: �7��(�«��j��c :� �J- S�US�0'�7S LOCATION OF SERVICE: 7�I/�J fn/ L3�}��el l?�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 � I Reduced Pressure Principle '�i Reduced Pressure Principle-Detectar �Double Check Valve ' I Double Check-Detector � 1 Pressure Vacuum Breaker '� I Spill-Resistant Pressure Vacuum Breaker Manufacturer �!\/a��s ModelNumber ��7�1/]� Size �� Located At C��' ��i°V ��. ��st V��n�t Serial Number /6/9l y Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �5 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 I Did not open I 1 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 ClosedTight f �� psid psid psid Test gauge used: Make/Model /-I�� SN: Q.i(1�DQ�g Date Tested for Accuracy: ,�-��- ,,�Q�� Remarks: The above is certified to be true at the rime of testing. Firm Name ,�/�� Firm Address /Q57 �is�� ,✓,k l�d. l��l��,s.�( �.jv�,��f Certified Tester(pr�nt) � v� Certified Tester(signature) Firm Phone#�/L/ - 3 L/G�-aa�/ Cert.Tester No. l3/��Ol��?f�1.3 Date y i.3��D/� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Custonler 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: CONTACT PERSON/PHONE: �,,;� Gu �� /��-(�f2, LOCATION OF SERVICE: 7�C�f� �I � The backflow prevention assembly detailed below has been tested and maintained as required by commission reguladons and is certified to be operating within acceptable paraineters. TYPE OF ASSEMBLY ' Reduced Pressure Principle Reduced Pressure Principle-Detector i✓Double Check Valve Double Check-Detector ' PressurcVacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer /—��j�� Model Number �j�Q Size o� � Located At � /19��8� �,,., �f�� V u�� Serial Number ��6�y Is the assembly installed in accordance with manufacturer recommendarions and/or local codes? YS Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve ]st Check 2nd Check Held at��psid Held at �o�,�psid Opened at Opened at Held at Initial Test Closed Tighti��/' Closed Tight �✓ psid psid psid Leaked'��I Leaked I Did not open i 1 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_; ClosedTight' I psid psid psid Test gauge used: Make/Model � SN: Q��Q 9�� Date Tested for Accuracy: �/' Remarks: The above is certified to be true at the time of testing. FirmName /-��/✓(,� Firm Address /��7� �is�s, ��i,✓k ,1��, l�i,��a� � 7,�"�.3� Certified Tester(pr��r) � c� Certified Tester(signature) �,�,r�„v� Firm Phone#��/U -,31/�- �,��Cert.Tester No. �I�OQ��?f/3 Date y-L3 -�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