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2016_0908 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) 1 MAILING ADDRESS: �303 �t�r�a I�i ��. ��C=��X 7SDI� CONTACT PERSON/PHONE: Le�.u; ' i 4 —�9�' � �'�v LOCATION OF SERVICE: f 3b3 (.Jr'� rr ir 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 i-Reduced Pressure Principle 1Reduced Pressure Principle-Detector i✓ISouble Check Valve �I Double Check-Detector f PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer �(�'�'�S Model Number �� 1�Y� � ��1 Size z�r Located At (,�I� o� � �- Serial Number � z�''!�"�1 S Is the assembly installed in accordance with manufacturer recommendations andlor 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 �� y psid Held at 2-0 psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight '�? psid psid psid Leaked�� I Leakedl '� Did not open f°�� Did not open I I Leaked� I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight�_1 ClosedTight��1 psid psid psid Test gauge used: Make/Model M br�C.O ��'Zo0`Tk SN: ZS SODD Date Tested for Accuracy: � � �J'� Remarks: The above is certified to�be true at the time of testing. FirmName I�OfJ(J�I� �� Firm Address 1�J�3��- 1 `-�r � �� jC �sO�� Certified Tester(print)�(��l��t� Certified Tester(signature) � � Firm Phone# �l� ' ��` —U�� Cert.Tester No.p��ss Date 7 D � * 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: � 3� � W ra r�q I�� r',r , C'v poe i( 't X �S�(� CONTACT PERSON/PHONE: ev�1� C� ' ZiC-1- y �� y� LOCATION OF SERVICE: I3o3 W rq rlq �r Li r 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 1 Reduced Pressure Principle I l�Rednced Pressure Principle-Detector �IDouble Check Valve 1Double Check-Detector 'PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer �^Q�U CC� Model Number � �� Size Z�� Located At IV E i+� o � S G Serial Number �-� �(o��j7 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �t5 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��0 psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight�pl psid psid psid Leakedl I Leakedl � 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 ClosedTightLl� ClosedTight'�_J� psid psid psid Test gauge used: Make/Model �(Yl�Cl� �l� �200 �� SN: Z��{��U Date Tested for Accuracy: -1 �l�''�l S Remarks: Tbe above is certified to be true at the time of testing. Firm Name �-O p p�� :SD Firm Address � � �1r' �� . , � Certified Tester(print) I '� Certified Tester(signature) Firm Phone# 2�� ' ��d�V Cert.Tester No. �P�d�o7s� Date � 0 � * 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 3C73 �ca,�c�ler C�r ��P��1X 75d I�1 CONTACT PERSON/PHONE: • ;5 i LOCATION OF SERVICE: l 3�3 �r��, �r ` � p��I 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 ��1Reduced Pressure Principle-Detector ;�oubleCheckValve � IDouble Check-Detector �PressureVacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker Manufacturer re� t�U Model Number �S�o�D Size Z.�� Located At 1`�o�� i�lc� Serial Number �—I U(o r}S`1 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? C 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�� b psid Held at Z,�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight ��F psid psid psid Leaked.l Leaked�-�� Did not open �i��; 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❑ Closed Tight i�l psid psid psid Test gauge used: Make/Model bra�.o y0��p0�K SN: ��S�� Date Tested for Accuracy: � /� /S Remarks: The above is certified to be true at the time of testing. Firm Name CpQQ��I -�� Firm Address �� 3 wra �� `-�1� �� Certified Tester(pr�nt) � 11G� k.X�f��_Certified Tester(signature) ' � Firm Phone# 2�`l- ��`�' U�� Cert.Tester No. � 7�� Date C/ � * 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