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2016_0621 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 TES1'AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040 (Customer) � MAiLING ADDRESS: �J ` V C� � ,�rJO I� CONTACT PERSON/PHONE: I " Co ' LOCATION OF SERVICE: i r� J 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 1i�duced Pressure Principle f 1Reduced Pressure Principle-Detector 1DoubleCheckValve ❑Double Check-Detector �Pressure VacuumBreaker I_'Spill-Resistant Pressure Vacuum Breaker ��C" ��SC� X fL� s�Ze 3 „ Manufacturer �i t fl� Model Number � Located At �n��„�,�� i�C3Y�i� �f'�f�U'�,. 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��ps' � Held at�� psi Opened at Opened at Held at Initial Test Closed Tight, Closed Tight �� psid psid psid Leakedf ; Leaked'-1 Did not open ; l Did not open _.l Leakedl '. Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight 7 ClosedTight f I psid psid psid Test gauge used:Make/Model V�l i 1 Pc j��, / 1 �37� SN: �$�(�j��Ql Date Tested for Accuracy: � —�,�� Ln Remarks: The above is certified to be true at the time of testing. Firm Nam�;sl�-,�� `�l�f'lcYt1S►`�/• �t�;Firm Address�0��- �93G��a�1��/I� ��7�j�� Certified Tester(print) S°�"P��1'l�iS�ertified Tester(signature) � � Firm Phone# ��—Co��3 Cert.Tester No�� '� � �Date�9—��—/(n * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE ✓ The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040 (Customer) � MAILING ADDRESS: � F �S �V Gp ! � X , ��ar9 CONTACT PERSON/PHONE: LOCATION OF SERVICE: ` � The backflow prevention assembly detailed below has been tested and maintained as required by commission regularions and is cerrified to be operating within acceptable parameters. TYPE OF ASSEMBLY ��1Reduced Pressure Principle ��uced Pressure Principle-Detector f�i Double Check Valve �Double Check-Detector �1PressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker i: Manufacturer�j(-�;�,� Model Number ��Pj Size�_ Located At �(1 �(�(..,� �f' ��i�p��i�'�� Serial Number �( ��.$ 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�e� psi Held at�psi 'Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leakedl ! Leaked�] Didnotopen C; Didnotopen [ � Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at OpenEd at Held at Repair Closed Tight I-� Closed Tight--1 psid psid psid Test gauge used: Make/Model �i�`C i 1'15 / 1 C-n� SN:�/��`j�j Date Tested for Accuracy: � -�]- �(� Remarks: The above is certified to be true at the time of testing. Firm Name�j� C��r�(,,(;+ �V•,T Firm Address I-U��,`��Ce4 I L t �SVi'��1�� '7�;� Certified Tester(print)��ie�lL�'1�j S�Certified Tester(signature) � Firm Phone#��'"�'�c 7�-��_ �; Cert.Tester No.�rCX��_Date �4'a (- �tp * 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) MatLrtv�aDD�ss: � o i � B� ' 75C�1� CONTACT PERSON/PHONE: - — j 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 C uced Pressure Principle ❑Reduced Pressure Principle-Detector � ouble Check Valve ' 1 Double Check-Detector �PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer V��i � �� I�'1� Model Number � Size �� ` � .J /' I�•O 1 Q � Located At �r1 V{�►U I` I` / ��f�7'�'Y�XitSerial Nu�m �� -I o�7 I 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�.� p�id Held at a.�psyd Opened at Opened at Held at Initial Test Closed TightF�{ Closed Tight � psid psid psid Leakedll I Leakedl�i Did not open '�7 Did not open C1 Leakedl. I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight L� Closed Tight��-1 psid psid psid Test gauge used: Make/Model �h�j� j '5�.�-3� SN:��E(g.�j� Date Tested for Accuracy: _(- 7�-f�,� Remarks: � The above is certified to be true at the time of testing. FirmName��ln�f��f�',�irm Address � ��.�_ � � �j)j��p",�'�"-��c� 1r ,� Certified Tester(print) � � i� Certified Tester(signature) � Firm Phone# c�,��p /�-� "�_Cert.Tester No�P rY��7D� Date �—�-]-�(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 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) Ma1LrNG a��REss: ' t \n! 1 Ccs eC I `T'x � 7�o►9 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 �7�duced Pressure Principle-Detectar Ci Double Check Valve I�Double Check-Detector '-1PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker N Manufacturer �'� k 1 ns Model Number ` �� Size�_ Located At.��F}(,t��"�5��"�N O'T � erial 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,' ,�p d Held at��ps Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leakedf 1 Leakedl I Did not open f I Did not open I I Leakedi�1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight I 7 ClosedTight❑ psid psid psid Test gauge used:Make/Model � I ��G ��11. ' �z SN:��'��_�Fl� Date Tested for Accuracy: -�-�""� � Remarks: ` The above is certified to be true at the time of testing. FirmName��}��rY��}�/,'�'irm Address �(>�_�Cf-� ' P/'o jS �j'�/ !TX'�Q�� Certified Tester(pr:nt)�'��ttC'�i�Certified Tester(signature) � � Firm Phone# ��07�-��j�f�_Cert.Tester Na��l � � � ��Date [g�`�,��-�(Q * 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