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2016_0811 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 a��xEss: %l�('�/�:� �� ,_ �'� P ��, �.�,�;��ll, ��7� �7.5:�i'7 CONTACT PERSON/PHONE: ti ,� � �� ' ' LOCATION OF SERVICE: �(�� 1� , 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 CReduced Pressure Principle �'�Reduced Pressure Principle-Detector C'�Double Check Valve [j�r�ouble Check-Detector �PressureVacuumBreaker f 1Spi11-ResistantPressure Vacuum Breaker Manufacturer �0�1�1�5 Model Number �i�� i� -�� Size � �, Located At ��>S�'i�" �r�c3�rr � Serial Number ��-�_��1� 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 �,'�t psid Held at�psid Opened at Opened at Held at Initial Test Closed Tighti� Closed Tight ��✓ psid psid psid Leakedf 1 Leaked'�.I Did not open I 1 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 C� psid psid psid Test gauge used: Make/Model � � SN: �,��,�j��rJ� Date Tested for Accuracy: - � � / Remarks: The above is certified to be true at the time of testing. Firm Name .�,�-`9'� Firm Address/(,�� 7� �,51"� �✓� /�:� /��ll��s, �X` ��'� .T--- Certified Tester(print) ° r� � / �> �,�, Certified Tester(signature) , �. �--� Firm Phone#�f�� f�� Cert.Tester No. ��f�,l��.� 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 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: ' �-. - /I �7 / CONTACT PERSON/PHONE: � LOCATION OF SERVICE: /()[�/ � .�vt�J„ ��ICP I�rI, 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_1Reduced Pressure Principle-Detector �ouble Check Valve C��Double Check-Detector ❑Pressure Vacuum Breaker ��1 Spill-Resistant Pressure Vacuum Breaker Manufacturer l-t�Pt Model Number��QQQ�/�/�� Size �/�/�' Located At ��iS��V lCdDt� � Serial Number ��j g�o� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �GS Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held atc,�,� psid Held at `o�,�psid Opened at Opened at Held at Initial Test Closed Tight�Y Closed Tight � psid psid psid Leakedl 1 Leaked❑ Did not open I Did not open I�l Leaked l I 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 � 0 SN: ��j Q�Q q�� Date Tested for Accuracy: ' Remarks: The above is certified to be true at the time of testing. Firm Name :��'Y� Firm Address/Q��j� �/,S�i� �v�C �c� �i��s,. j�1' 7�i�,�� Cerrified Tester(pr:nt) lJ�'S�t�,� /h�vhy,�,✓� Certified Tester(signature) _ � Firm Phone#�� -��-.�.�:�� Cert.Tester No.��%J�J��/� 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 IRRIGATION DOMESTIC FIRELINE � The following farm must be completed far each assembly tested. A si�ned 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: � � I� J 7 � 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 C�:Reduced Pressure Principle I Reduced Pressure Principle-Detector I�I Double Check Valve �ouble Check-Detector rlPressureVacuumBreaker i ISpill-Resistant Pressure Vacuum Breaker Manufacturer ��t�t Model Number [�� jQ�A -,�j� Size �j „ Located At ��s�l� /C�1Dt��+ �� Serial Number �- f� (�Q�� 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 Initial Test Closed Tight�l� Closed Tight f✓ psid psid psid Leakedl I Leaked .I Did not open I I Did not open f Leakedl Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTightl '�� ClosedTight� I psid psid psid Testgaugeused: Make/Model Aod�� SN: (��Q(��9�jg Date Tested for Accuracy: � - %� /� Remarks: The above is certified to be true at the time of testing. Firm Name f�� Firm Address �(�5 7� Vst�i �ca✓� /��, �,��E�s°.�.� 7�c�3� �� Certified Tester(pr:nt) ' � � �o Certified Tester(signature) ,_ � v, ,�_ Firm Phone# � ��-.��/��a�/ Cerk Tester No.�f�QQ/��_j 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 IRRIGATION DOMESTIC FIRELINE J� 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: A/I LOCATION OF SERVICE: 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 ! Reduced Pressure Principle ' Reduced Pressure Principle-Detectar ��oubleCheckValve ��'��Double Check-Detector !PressurcVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer /�m�.S Model Number aoDo��3 Size 3�t/ �� Located At /�i_SPr ��o�rr f� Serial Number Q�79 c� Is the assembly installed in accordance with manufacturer recommendations andlor local codes? TCS Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air lnlet Check Valve 1 st Check 2nd Check Held at�,�psid Held at�psid Opened at Opened at Held at Initial Test Closed Tightf✓ Closed Tight � psid psid psid Leaked I Leakedl Did not open Did not open ' Leaked Repairs/ Materials Used Held at psid Held at psid Test After Opencd at Opened at Held at Repair ClosedTight� I ClosedTight I psid psid psid Test gauge used: Make/Model Ar1n��G SN: Q�(J6(}��j� Date Tested for Accuracy: �- /.,?- �� Remarks: The above is certified to be true at the time of testing. FirmName ��- �� Firm Address_�QS�'S �st�,� ��,� �;� �a�� ( ]j��3� Certified Tester(prpnt) � � �� ; � ��ps�Certified Tester(signature) vy,� Firm Phone# �/��,�q-��,�/ Cert.Tester No. b'1�(��/a�/3 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 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: I L � . I ��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 �educed Pressure Principle-Detector '��I Double Check Valve ouble Check-Detector :1PressureVacuumBreaker '�!Spill-Resistant Pressure Vacuum Breaker Manufacturer �m�S Model Number�ol� 300a��F Size y�� Located At_�.,S�v ��oarr A Serial Number ��-4;3[j�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �S Reduced Pressure Princi ]e Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at�psid Held at y,( psid Opened at Opened at Held at Initial Test Closed Tightl►� Closed Tight Ivl� psid psid psid Leaked I Leakedl Did not open ' Did not open . l Leaked ' Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight C] psid psid psid Test gauge used: Make/Model A�af�D SN: (�3(��Q�� Date Tested far Accuracy: a-��-��j Remarks: The above is certified to be true at the time of testing. Firm Name ��i�C�� Firm Address /Q��S 1�i_S�a ,�d✓k ��, �aJ��J� /��t�� .� Certified Tester(prtr�t) � �., Certified Tester(signature) Firm Phone#� /� _,�U9-.��/ Cert.Tester No.��/,�(�%� Date 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 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: IO' ' � '� 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 C7Reduced Pressure Principle �Reduced Pressure Principle-Detectar I�ouble Check Valve [1 Double Check-Detectar �]PressureVacuumBreaker C_Spill-Resistant Pressure Vacuum Breaker Manufacturer VI/�,�i�S ModelNumber �/�(��`f7/1�9.��T Size �1t.� "" Located At��,�f��- ��ps� � Serial Number��y�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �G5 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�U'`� Closed Tight �1� psid psid psid Leaked'.I Leaked' I Did not open I ' Did not open I Leakedi ' Repairs/ Materials Used Held at psid Hefd at psid Test After Opened at Opened at Held at Repair Closed Tight� �1 Closed Tight Ci psid psid psid Test gauge used: Make/Model � p �� SN: (�,�(�f-,r�i�� Date Tested for Accuracy: � - � -/� Remarks: The above is certified to be true at the time of testing. FirmName �-�� FirmAddress%(�5��/� p,/,�� '�,�,� �%,.. 1��,//e,;� T�� '7�;��'� , Certified Tester(print) � r��a�,�� ar,��a,� Cerrified Tester(signature) .�u� �- Firm Phone# .�l��--/ �'��-.�� Cert.TesterNo.�p{,A(�/�f/`� Date 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