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Duke Freeport- LR160516a r IRRIGATION DOMESTIC FIRELINE ►/ The following form must be completed for each assembly tested. A signed and dated origin must be submitted to the public water supplier for recordkeepi. g purposes: 1 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # (1570040 (Customer) MAILING ADDRESS: T CONTACT PERSON/PHONE: LOCATION OF SERVICE:; The backflow prevention assembly detailed below has been tested Ind maintained as required by commission regulations and is certified to be operating within accept ble parameters. TYPE OF ASSEMB Y L IReduced Pressure Principle FIReduced Pressure Principle -Detector Double Check Valve �uble Check -Detector -1 PressureVayc`uurnBreaker : Sp ]l -Resistant Pressure Vacuum Breaker Manufacturer L , S Model Number S S J Size Located At �j „ ! J i.Ij c ai r ti y7 Seri Number _Z � 'j Is the assembly installed in accordance with manufacturer reco endations and/or local codes? , Reduced Pressure Principle Assembly Pressure Vacuum Breaker Double Check Valve Assembly Relief N aloe Air inlet Ch ck Valve 1 st Check 2nd Check Held at2 Z- psid Heid at � psid Opened at Opened at Held at Initial Test Closed TightF-t— Closed Tight 1; – psid psid psid Leaked I Lcaked5 Did not open Did not open Lea edL Repairs/ Materials Used Held at psid Held at psid Test After Closed TiOpened at Opened at Held t Repair ght - Closed Tight J psid psid psid Test gauge used. Make/Model i'.e i ' l f� SN Date Tested for Accuracy: G)iid C. Ci , The above is certified to be true at the time of testing_ Firm Namedress Finn A d Certified Tester (print) ' { � 'Cd:� f Certified Tester (signature) Firm Phone # '�{ t `a'I' Cert. Tester No. r * TEST RECORDS MUST BE KEPT FOR AT LEAST THRI * * USE ONLY MANUFACTURER'S REPLACEMENT PAR White- City Copy Yellow- Customer Col YEARS Date Pink- Tester's C IRRIGATION DOMESTIC FIRELINE L" The following form must be completed for each assembly tested. A signed and dated origi must be submitted to the public water supplier for recordkeepn-rg purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPOR NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS:I-,; CONTACT PERSQN/PHONE: LOCATION OF SERVICE: " S e- r r �"s ,a ,j 12/, 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 -Detector Double Check Valve ruble Check -Detector 5 Pressure VacuumBreaker Spill -Resistant Pressure Vacuum Brea Manufacturer y t — R Model Number `� 1 _`.ate � k�J Size Located At CJ w 1 /t 1 r r v- r p Serial Number S Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi leAssembly Pressure Vacuum Double Check Valve Assembly Relief Valve Air Inlet 1st Check 2nd Chcck Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at field at Repair Closcd Tight :. Closed Tight -1 psid psid psid i Test gauge used: Make/Model }� Date Tested for Accuracy:, e Remarks: The above is certified to be true at the time of testing. SN: Firm Name 1 Firm Address ¢�� 1i r Certified Tester (print) f' -1 �`' - I ' ?C.f,t1-!E�lt1. Ce Tied Tester (signature) 7 Valve Firm Phone # Old 1 ." t( 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 Cop Held at S` psid Held at � ---psid Opened at Opened at Held at Initial Test ClosedTight� Closed Tight ---'' psid psid psid Le akedl Leaked-] Did not open Did not open' I. Leaks+ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at field at Repair Closcd Tight :. Closed Tight -1 psid psid psid i Test gauge used: Make/Model }� Date Tested for Accuracy:, e Remarks: The above is certified to be true at the time of testing. SN: Firm Name 1 Firm Address ¢�� 1i r Certified Tester (print) f' -1 �`' - I ' ?C.f,t1-!E�lt1. Ce Tied Tester (signature) 7 Valve Firm Phone # Old 1 ." t( 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 Cop IRRIGATION DOMESTIC FIRELINE �.** The following form must be completed for each assembly tested. A signed and dated origin 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: I CONTACT PERSON/PHONE: 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 Double Check Valve double Check -Detector Pressure Vacuum Breaker —Spill -Resistant Pressure Vacuum Brea 01-7 Manufacturer i, I L <- ��'" + � � � Model Number �' Size `4 Located At Serial Number `? �J 9 341� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Principle As en-ibiy Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve 1st Check 2nd Check Air Inlet Ch eck Valve 3 Held at 7 L psid Held at ` a psid Opene=Opened Held at Initial Test Closed Tight ^ Closed Tight Ii� psidpsid Leaked' Leaked -i Did notLeaked Repairs/ Materials Used `fest After Held at psid Held at psid Opened at Opened at Held at Repair Closed Tight 1 Closed Tight I psid psid psid Test gauge used: Make/Model Lt j(l ' ( %{?Y SN: Date Tested for Accuracy: C : Remarks: The above is certified to be true at the time of testing Firm Name ooliit,t' f'. ! ( Finn Address #` Certified Tester (print)_.Certified Tester (si-nature) Firm Phone # ��' i,-� l ;' l Cert. Tester No. Date TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White- City Copy 'Fellow- Customer Copy Pink- Tester's Copy 1 t IRRIGATION DOMESTIC FIRELINE The following forty 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: cs'Ih c+ f -�. ► l i' S !- : e e CONTACT PERSON/PHONE: LOCATION OF SERVICE: L -1- S l 'r' .e e P ,;f -1 —F7/-,,- E _ 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 TlReduced Pressure Principle []Reduced Pressure Principle -Detector Double Check Valve -ruble Check -Detector �]Pressure Vacuum Breaker -Spill-Resistant Pressure Vacuum Brea Manufacturer 11 L ,_ S Model NumberZ '' Size ; Located A�.I;' Serial Number Is the assembly installed in accordance with manufacturer recommendations and/or local codes?,,, f Reduced Pressure Principle Assembly Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve 1 st Check 2nd Check Air Inlet Check Valve Held at `j psid Held at '" y psid Opened at Opened at Held at Initial Test ClosedTi ht _ Closed Tight psid psid psid Leaked Leaked Did not open 1 Did not open I Leaked I Repairs/ i �. _ .4 C. I rc" .. - J Materials Used e? Held at psid Held at psid est After Opened at epair Closed Tight Closed Tight L Opened at Held at psid psid psid Test gauge used: Make/Model 444-7- 5 RX `-f' t: SNe f^ Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. Firm Name Firm Address t}� Certified Tester rrnt ' (P ) � • . '�'`� `r �' �i �°' � f"t-` Certified Tester (signature) ' j- Firm Phone # 7C'; E) t { l� 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