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2016_0413 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: _/�/��// lV j��,,ll�,s l�k�,,,�.,. #/p2C� !�«//as T�( 7_ a 4 CONTACT PERSON/PHONE: . -� - - f�]� LOCATION OF SERVICE: �Q� W 13e� �� I 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 � IReduced Pressure Principle I ��Reduced Pressure Principle-Detectar ��1DoubleCheckValve 3QDouble Check-Detector 'PressurcVacuum Breaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer �/1�c�-��,� Model Number 77�/,��/�,�_Size " Located At ��ST �G N�� . Uet�c°� /'C�. Serial Number jQ g 7�7 Is the assembly installed in accardance with manufacturer recommendations and/ar local codes? Y�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 TightJ� Closed Tight I � psid psid psid Leaked� I 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 ClosedTightl '�� ClosedTight I psid psid psid Test gauge used: Make/Model SN: Q,��fj��6 g Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. FirmName �� Firm Address ��jl7j� Vs�� Ga✓�i' ��. ��o�s �i� 7J�o�� Certified Tester(print) ��y�j yd, � ay„��,;,,Certified Tester(signature) � Firm Phone#a��-3U�-.� �� Cert.Tester No. ��D�a6�� Date y-�,3-o��/�j * 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 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: � #�l U 7 a�U CONTACT PERSON/PHONE:1�o� �jti ✓ir aiy-54�-a`75 LOCATION OF SERVICE: �UO W /3e��iPl /�c�. The backflow prevention assembly detailed below has been tested and maintained as required by commission reguladons and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ' Reduced Pressure Principle ' Reduced Pressure Principle-Detector l�pouble Check Valve �� Double Check-Detector ! Pressure Vacuum Breaker ' Spill-Resistant Pressure Vacuum Breaker Manufacturer �/�✓�,�t�i'S` Model Number ��)7/�,�� Size 3/y ,� Located At ��±5t V�u�t ��fG�� K�/. Serial Number 135U/ 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�,Q psid Opened at Opened at Held at Initial Test Closed TightJ� Closed Tight .� psid psid psid Leaked I Leakedl I Did not open � Did not open � I Leakedl Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight'..1 Closed Tight I psid psid psid Test gauge used: Make/Model � SN: (130��9� � Date Tested for Accuracy: -/, - Remarks: The above is certified to be true at the time of testing. FirmName ��/�� Firm Address � ��_ 75 i✓,S-�� ✓� �� ,��sis� l� 7J�v7,3�� Certified Tester(prr�t) � r� Certified Tester(signature) Firm Phone#a/�-3�{��-��1 Cert.Tester No.��il�'/��/3 Date yu%3 ��o��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 ariginal 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: U / � / /� � 7 CONTACT PERSON/PHONE: I - Uf�-O/7 LOCATION OF SERVICE: ' VI/ 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 ��iReduced Pressure Principle ��IReduced Pressure Principle-Detectar �DoubleCheck Valve � !Double Check-Detector � IPressurcVacuumBreaker '��iSpill-Resistant Pressure Vacuum Breaker Manufacturer �/�/�yTs" Model Number QQ7�� Size �� Located At �/VIP�"��v G'��5� VG1N�� Serial Number I��16g 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 1,�psid Held at�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked ''� Leakedl ' 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 I � Closed Tight �I psid psid psid Test gauge used: Make/Model �I h�r/�� SN: �.� ��g �___ Date Tested for Accuracy: a -/� - �� Remarks: The above is certified to be true at the time of testing. Firm Name ��-��J Firm Address ��7� �'is�G� ��ci✓� ��. /J��5; � 7�� 3 � Certified Tester(pri�t) � t�Certified Tester(signature) ,,.,� C/,(,r,�..wv�-_ Firm Phone# a1/L/-3�C/•�070�� Cert.Tester No./�pOD/,��/� Date L/-I_�-�(j'I� * 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 J� 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: l�Io?�JI IlJ �is,lI�s �k�..n._ #IL�DD >>o,/Icris. TX 75vZr�/ CONTACT PERSON/PHONE: -O/7 LOCATION OF SERVICE: �(J W I3c° �P� 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 �� iReduced Pressure Principle I��Reduced Pressure Principle-Detectar i�ouble Check Valve Double Check-Detector I��'Pressure VacuumBreaker � �Spill-Resistant Pressure Vacuum Breaker Manufacturer /—�hL� Model Number ��Q Size �� Located At �1�'��t� �� eSf' V v��f Serial Number ��q�,S� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 7'GS Reduced Pressure Princi le Assemb] 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 .I� psid psid psid Leakedl I Leaked. I Did not open f I Did not open '� Leakedi Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight I 1 Closed Tight� I psid psid psid Test gauge used: Make/Model�,��0 SN: �3��a� Date Tested for Accuracy: -/v�-��/�? Remarks: The above is certified to be true at the time of testing. Firm Name .�� Firm A ddress�(}_S75 Vis�i� �n✓�: ��. ��,��i s.T� 75r�3� Certified Tester(prf nt) � � � � vv� o1n Certified Tester(signature)��.,�, � �,v�.—.� Firm Phone# ��y-3L�9-��1 Cert.Tester No. f��QQ/,�fJ/.� Date y '�3-��/� * 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