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2016_0805 IRRIGATION DUMESTIC FIRELINE� The following form must be completed for each assembly tested. A signed and dated original must be submitted to the p��blic water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040 (Customer) �{ �Q MAILING ADDRESS: , �� t �S'� '� 1`� . CONTACT PERSON/PHONE: �' i S 1 — LOCATION OF SERVICE: L 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 ❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector �pouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-ResistantPressureVacuum reaker 1 _ r�q; , 3� // Manufacturer W�\�� Model Number � Size � � a� y `7� Located At �U �� '�✓� Serial Number 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 lst Check 2nd Check Held at�psid Held at{• psid Opened at Opened at Held at Initial T� Closed Tight� Closed Tight �C psid psid psid Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑ R airs/ Materials Used Held at psid Held at paid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid 1 S S sNo�07 � 7g `f Test gauge used:Make/Model i �� Date Tested for Accuracy: S �� Remarks: � The above is certified to be true at the time of testing. 0 ° � ol FirmName�l -�� V� Firm Address �p� �� ' �T' � 1/ k5o v� �-(,�e,r'�T�• Certified Tester(print) I�'1 C� �� Certified Tester(signature Firm Phone# � L �' ✓ � ��"' Cert.Tester No� �` `�� ate � v *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 FIRELIN� The following form must be completed for each assembly tested. A signed and dated original must be submitted to the plablic 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: l — LOCATiON OF SERVICE: ( D � � • The backflow prevention assembly detailed below has been tested and maintained as required by com 's ' n regulations and is certified to be operating within acceptable parameters. ' �1 TYPE OF ASSEMBLY �./ � �IReduced Pressure Principle ❑Reduced Pressure Principle-Detector `�Double Check Valve ❑Double Check-Detector ��PressureVacuum reaker ❑Spill-Resistant Pressure Vacuum Brlaker ' � f �� 7 / � Manufacturer W Model Number � l. Size � Located At l�, �1�v �� Serial Number � Is the assembly installed in accordance with manufacturer recommendations and/ar 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 '�psid Held at J' psid Opened at Opened at Held at Inkial Test Closed Tigh Closed Tight psid psid psid � Leaked❑ � Leaked❑ Did not open ❑ Did not open ❑ Leakedn Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i 7 Closed Tight 1=I psid psid psid Test gauge used:Make/Model V v 1 l ��V15 �lJ�-� SN; �(j ��l �O y Date Tested far Accuracy: S/ � �,� b Remarks: The above is certified to be true at the time of testing. Firm Name ��, I, \ e�� Firm Address�� S �`` f�� • �� / o n �� ,T1c • � Certified Tester(print)1-� � �e'�� Certified Tester(signature) Firm Phone# �I7�� `��`S�Cert.Tester No�P �0�'" � I��- Date v! T ` * 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) � � � 1 i�� 'Q�� MAILING ADDRESS: � W Y � CONTACT PERSON/PHONE: — � '�� .-S � LOCATION OF SERVICE: rJ L 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 ��lReduced Pressure Principle ❑Reduced Pressure Principle-Detector �Double Check Valve ❑Double Check-Detector ❑PressureVacuum re er ❑Spill-Resistant Pressure Vacuum Breaker ��` a c� Manufacturer �/" U` Model Number �/� 1� Size � Located At I � " �� W �'L�`� � �Seria�'Number O 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� '� psid Held at I'� psid Opened at Opened at Held at In' 'al��f Closed Tigh�, Closed Tigh� psid psid psid � � Leaked❑ Leaked❑ id not open ❑ Did not open ❑ Leaked❑ Rep irs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight J Closed Tight❑ psid psid psid ��S Test gauge used: Make/Model I�► �,�--lY\S �� SN:��'� �� [ D ( Date Tested for Accuracy: �^L��b Remarks: The above is certified to be true at the time of testing. � c � n /� . ��`�pl Firm Name ��,1 Te J� Firm A ddress �'�/ b � �� or � e i Certified Tester(print) � �� Certified Tester(signature) Firm Phone# D ��—� 7�� o'S� Cert.Tester No�� Date g S l G * 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 C�IECK �NE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAIIV'I'ENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # � � e 1 I o� s � � LOCATION OF SERVICE: � a�L� �,.J e� De��- I � ` The bacl�low przveation asscmbly detailed below h� beea tested aad ma�ntain� � nq�� bv TNRCC re_�ons aad is certified to be operating withia acceptablc paramcters. D J� TYPE OF ASSEMBLY �" C Reduced Pressvre Principle C Pressurc Vacu�Breaker � Double Check VC ve o Atmosphere Vacuum Breal:er �,To�k� 1 a '� Manufacnaer , Siu Model Number � � 1 � L��' Locaud At 1`� �`Q� \� bB`-C., � S��N�ba � Q o 3 �y - � 9 � REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CW.M BREAI�R Double Cherk Valve Assembly lst Check 2ad Chec1: Relief Valve Air Inl�t Check Valve Inival Test GClos losod Ti � Opeaed at Opened at _osid �� 1 � L - o Dsid osid a RP-_psid o` Leal:ed o �j ' �' Did not Opea o Leal:ed � �P� aad �- Mataials Usod � Test Aft�er DC-Closed Closed Tight o Opened at Opmad at __nsid .._ � Repair Tight � �sid osid R.P sid The above is cari6od to be true. Firm Name �` ` —�e � Catified Testa 9-•(J'o��S 0� Firm Address I�6S K D��I 1'a' S�' Y�l Cat Te.ster No. `00 I I� I 7� D� D S I � (C21�X-7L�`f� Gauge # ��7'7� 1 llate last accuracy tested � 3 � 6 White- Customer's Copy Yellow - City Copy Pink-Tester's Copy