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2016-1010 IRRIGATION DOMESTIC l ' FIRELINE The following form must be conlpleted for eacl� asseinbly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping ptn�poses: BACKFLOW PREVENTION ASSEMBLY 1T/E�ST AND MAINTENANCE R PORT �6�`�F��' JT��' �' s� � NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (C�istomer) Q �' 0� � O �U�b�L�� • 7 I �a�.� MAILING ADDR�SS: 7� �� h ��' CONTACT PERSON/PHONE: O 6 — — 3 6( LOCATION OF SERVICE: Znk a • GO The backlow prevention asseu7bly detailed below has been tested and maintained as required by comn�issioi�regulations and is certified to be operating within acceptable�arameters. TYPE OF ASSEMBLY ?�Redliced Pressure Principle I�Reduced Pressure Priuciple-Detector � i Double Check Valve � 1 Double Check-Detector I IPressur�VacL�umBreaker � 1Spi11-Resistant Presslzre Vacuuin Breaker lnf`r�a'kS ��2 �� Manufacturer Model Nlimber �0� Size Located At ��'�`��e �0 �� Serial Number I't �� Is the�ssembly installed in accordance with manuf3cturer recottunendations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacu�ml Breaker DouUle Check Valve AssemUly Relief Valve Air Inlet Clleck Valve 1 st Check 2nd Check �� S5 Held at�'�psid Held�tU�psid Opened�t�` � Opened at Held at Imtial Test Closed Tightl�(� Clc�sed Tight� �sid psid psid Leakedf I Leaked�I Did not ope❑ '� I Did not open I I Leakedl i Repairs/ Materials Used Held at psid Held at psid Test After Ope��ed at Opened at Held�t Repair Closed Tight'� l Closed Tight I I psi� psid psid Test gauge used: Make/Model�a 1�--l n 5 T �], J SN: 0�� V l Date Tested for Accuracy: � � �� b Re�r�arks: The above is certified to be true at the time of testing. FirmNa�ne ��'��5� Firn� Addresl ( �� ^�`� . cS�.�o1 S� � K�..� ��JTX-7L�'S� Certified T�ster(pr;nt) �� Certified Tester(sig�lature) Fii7n Phoile#� ��7� '��S� Cert.Tester No.P �0�� 7v1 Date � � ��'� � �` TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS W}ute- City Copy Yellow-Custoiner Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE The following form must be coinpleted for each assembly tested. A sigiled and dated original �nust be submitted to the public water supplier for recordkee in�u�o�ses:� �� l�D��f l�c-�- S�� BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS 1.D. # 0570040 (Custoi��er) � �' D� � O �U�b'�C��. • 7� �e�-3 MAIL[NG ADDRESS: •�� h ��' CONTACT PERSON/PHONE: O � — ' 3 6I LOCATION OF SERVICE: 2+�� a • �0 The backilow prevention lssembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable pasau�eters. TYPE OF ASSEMBLY �Reduced Pressure Principle f 1Reduced Pressure Priuciple-Detector � IDoubleCheckValve �1Double Cl�eck-Detector !�IPressurcVacuuulBreaker �-ISpill-Resistant Pressure Vacuum Breaker e�k k S ►� Manufacturer W Model Number �0�YY1 � Size � Located At ��'�� 0� � Serial Number �"1 � �� Is tl�e assembly installed in accordance with nlanufacturer recoirul�endations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Relief Valve Air Inlet Clieck Valve 1 st Gheck 2nd Check '�d��S Held 1t�'� ��sid Held at�'� psid Opened at�' � Opened at Held at InitialTest ClosedTigl�tl I ClosedTight�l, ps�� Psui psid Leakedf I Leakedl I Did not opeu '� 1 Did not open I I Leaked'�� I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held aY _ Repair Closed Tight i_l ClosedTight� I psid psid psid Test gauge used: Make/Model�a�i I15 T ��j, J SN: �� V 1 Date Tested for Accuracy: � �3�� b Remarks: The above is certified to be true at the tiiiie of testing. Firm Name ! 11�' \ �5� Fir-m Addres` � �b �—�`� . cSa'.�,o1 S� � �.-` ��1�K-7L�'� Certified Tester(}�ri��t) ��'� Certified Tester(sigtiatw-e) �� Firn1 Phoile#� ��7� ��S� Cert.Tester No.P �� 7� Dale � � ��'� � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Custoiner Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE The following form must be completed for each assembly tested. A sigued and dated original inust be subn�itted to tl�e plib1ic water supplier for recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TF„ST�A�ND..M#AIN�FNA�N��REP,pR�� ll� �.�}- J� �,' NAME OF PWS: CITY OF COPPELL PWS 1.D. # 0570040 (Custon7er) � p � MAILING ADDRESS: � (� 6 a �' �h � o P��e�. t,u bb��-�x � �� `�� CONTACT PERSON/PHONE: O � — "3 6 I LOCATION OF SERVICE: Zl�-1r o� • �0 The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable l��r�meters. TYPE OF ASSEMBLY �iReduced Pressure Principle f�Reduced Pressure Priuciple-Detector '� iDoub1eC11eckValve ��1Double C'heck-Detector I IPressurcVacuumBreaker i-lSpill-Resistant Pressure Vacuutn Breakec Manufacturer �� Model Number�� Size '�� Located At (�O �� - � �� n � Serial Number� � � �� Is the assembly installed in accordance with manufact�u-er reconuuendations andlor local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check P�� Held at v�� psid Held at( ' " psid Opened at �• " Opened at Held at Initial Test Closed Trght�.,l Closed Tight 1�, Ps�� 4�51{ Ps�� Leakedf I Leaked'�-I Did not open '� 1 Did not open I I Leaked'� I Repairs/ Materials Used Field at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight I �I Closed Tight f i psid psid psid Test gauge used: Make/Model�a 1�-i 11 S T ��j, J SN: �� V l Date Tested for Accuracy: � �3�� b Remarks: The above is certified to be tnie at the time of testing. Firm Naine ��'��5� Fii-m Addresi � �� "�``� . S�•�o1 S� � �.` L�I�K-7�� Certifieci Tester(prfr�t) ��'� Certified Tester(sigiiature) Firm Phone# � ��7� �� 0 S� Cert.Tester No.P �0�� 701 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 aud dated original mlist be submitted to tl�e public water supplier for r�cord�k� ��p�po�„s�� -T . BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) •7 V 3� � � O�h d O U I��C., L�—��. • 7 I !d�-� MAILING ADDRESS: ��• v CONTACT PERSON/PHONE: O 6 — " 3 6I LOCATION OF SERVICE: �nk o� • CO The backflow prevention assembly detailed below has been tested and maintained as required Uy commission regiilations and is certified to be operating within acceptable p�raiueters. TYPE OF ASSEMBLY �Reduced Pressure Principle (�Reduced Pressure Priuciple-Detector �� iDoubleCheckValve �1Double Check-Detector '��IPressurcVacuumBreakei- i-�S�ill-Resistant Pressure VacLium Breaker Manufacturer �" ��S Model Number ��/ Size ��'" l' ,�` 3 Y 7� Located At �� ► '�"�� Uh��'� � Serial Number � � Is the assembly installed in accordance with manufacturer reconunendations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker DouUle Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check �� Held at�psid Held at�� psid Opened at�• U Opened at Held at Initial Test Closed TightT� Closed Tigl�t'�Q �sid psid psid Leakedf I Leaked! I Did not open '� I Did not open ! I Leaked! I Repairs/ Materials Used Held at psid Held at__psid Test After Openecl�it Opened at Held at Repair Closed Tight'� 1 Closed Tight': I psid psid psid Test gauge used: Make/Model II��11�-- i115 T C�, J SN: �� V I Date Tested for Accuracy: � �3�� !o Remarks: The above is certified to be tr�ie at the time of testing. Frrn�Name ��'�� Firm Addres� ( �� `� • �'�•�� S� � Ke.� ��JTK-7G1`� Certified Tester(pr;nt)�� 1� Certified Tester(signature) Firui Phone# D �2�✓7� "-� D 5� Cert.Tester No.P �0�� b�7d� Date 1� ��,� �� 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 tl�e pub1ic water sLipplier for recordkeeping purposes: � � BACKFLOW PREVENTION ASSEMB4,Y TEST A D MA[NTENANCE REPORT /�,�t�f K-�� S � � NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) 7� J� Q � �`Y\ � � !'�� l�V I��L��. � 7 I �a�-� MAILING ADDRESS: � ' CONTACT PERSON/PHONE: O � — "3 6( LOCATION OF SERVICE: 2nk v� • CO The backflow prevention asseinbly detailed below has been tested and maintained as required by connnission regulations and is certified to be operating within accept�ble parameters. TYPE OF ASSEMBLY �.Reduced Pressure Principle f�Reduced Pressure Priuciple-Detectar ' iDoubleClleckValve I 1Double Check-Detector I�IPressui•cVacui�inBreaker i-ISpill-Resistant Pressure Vacuum Bre�ker �,,/'d1�-I'� l� I t Manufacturer Model Number �� 6 Size � Located At�'j0�� U�� n� Serial Number � � �V�� Is the assembly installed in accordance with manufacturer reconul7endations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve AsseinUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check `Q� ✓ Held at�� psid Held at " '�psid Opened a�� Opened at Held at Initial Test Closed Tight�(I Closed Tight I�, �sid psici psid Leaked[ I Leakedl�I Did��ot open i 1 Did not open ! 1 Leaked, I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Op�ned at Neld�t _ Repair ClosedTight'� l ClosedTightf�l psid psid psid Test gauge used: Make/Model�a 1�--l n 5 T �],� SN: �� V 1 Date Tested for Accuracy: �3�� b Remarks: The above is certified to be true at the time of testing. Fir�nNa�ne �1�'��5�" Firnl Addres` � �b �^�``� • cS�•�� S� � Ke-� L�JTI�-7G�-`� Certitied Tester(pr�nt) �� Certifieci Tester(sigiiature) Firm Phone#�� !� —��5� Cert.Tester No.P �0�� b�701 Date �� p '� � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS Wlzite-City Copy Yellow- Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE The following form must be completed for each assembly tested. A signed mld dated original �nust be submitted to the public water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND M TENANCE REPORT M�-r�-� ��-�-e -� � S 6 � NAME OF PWS: CITY OF COPPELL PWS l.D. #0570040 (Customer) � Q (' O�h ,� O ��. �U��`�C.��. • 7 1 ��'� G4 MAILING ADDRESS: 7 � CONTACT PERSON/PHONE: O � — — 3 6( LOCATION OF SERVICE: 2n� o� - �0 The backflow prevention asseinbly detailed below has been tested and maintained as required by cominission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY !�QReduced Pressure Principle I�Rednced Pressure Priuciple-Detector � iDoubleCheckValve ��lDouble Check-Detector f IPressurcVacuulnBreaker �ISpill-ResistantPressure Vactitum Breaker I - (� I�� Manufacturer W �� Model Number Size Located At ��`�` �� ' U �� Serial Number�" � � U� � Is thc asse�ubly installed in accordance with nlanufacturer recoln�nendations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet C'heck Valve I st Check 2nd Check �� Held at�� psid Held at`o� " psid Opened�t �• ✓ Opened at Held at Initial Test Closed Tigh�l Closed Tight`I� }�s�� psid psid Leakedf I Le�ked I I Did not open '� I Did not open i I Leaked I I Repairs/ Materials Used Held at psid Held at psid Test After Opened.it Opened at Held at Repair Closed Tight I 1 Closed Tight' I psid psid psid Test gauge used: Make/Model��l I�-- l n 5 T �,� SN: �� V 1 Date Tested for Accuracy: � �3�� b Remarks: The above is certified to be tru�at the time of testing. Firm Natne ! 11�'T�S� Firm Addres1 � �b �`� . S�.�o1 S� n K�..� ��1TX-7��'� Certifiecl Tester(pr�r�t) �� Cerrified Tester(signature) Fii7n Phone# 17 �� ! ^� 5� Cert.Tester No.P �0�� b�7� Date � � ��p '� � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White- City Copy Ye11ow-Customer Copy Pii1k-Tester's Copy IRRI6ATION 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 pur oses: M,o��`�e--� S��-� �F5 � � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. # 0570040 MAILING ADDRESS: ��3� � r �`Y1 � � �� `��—�� • �� °Z� CONTACT PERSON/PHONE: O 6 — "3 6 I LOCATiON OF SERVICE: 21�-�r o� • GO 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 i i Double Check Valve Double Check-Detector ! iPressureVacuumBreaker ' Spi11-Resistant Pressure Vacuum Breaker � �(' Cp� � 11 Manufacturer W�k�J Model Number �Q l Size /�'" v �r��l! Sl��.��-b a r s�°r�.� e. �.-7 a-�t � S Located At 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�psid Opened at `ll/ Opened at Held at lnitial Test Closed Tight�� I Closed Tight . I psid % psid psid Leaked� Leaked�l Did not open Did not open I Leaked '� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Hcld at Repair ClosedTight I 1 ClosedTight I psid psid psid Test gauge used: Make/Model 11��l� l 11 S T C�, J SN: �� V 1 Date Tested for Accuracy: � �3�� Remarks: The above is certified to be true at the rime of testing. FirmName �I�� \ �5k Firm Address � �� ^�"� • S�•1.01 S� n �-��/T1c-7��-`� y Certified Tester(pr�nt) �� Cerrified Tester(signature) Firm Phone# � ��J 7"1 �� D 5� Cert.Tester No.P �0�� b�7� Date �� p �� * 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 inust be completed for each assembly tested. A signed and dated original must be sub»�itted to tl�e public water supplier o-recordkeeping puiposes: � .M,e�r s-�� 5 � BACKFLOW PREVENTION ASSE BLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS 1.D. # 0570040 � (Custoiner) MAILING ADDRESS: �3� Q � �`Y� � � ��• �� `�L�� • �� CONTACT PERSON/PHONE: O � — —3 6 I LOCATION OF SERVICE: �n�r v� • �0 Thc backilow prevention assembly detailed below has been tested and maintained as required by commissioi�regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY '�educed Pressure Principle I�Reduced Pressure Principle-Detector !� i Double Cl�eck Valve �1 Double Check-Detector I 1PressurcVacuLimBreaker ��Spill-Resistant Pressure Vacuum Breaker n � I � Manufacturer �� Model Number � 'V � Size Located At 1� �./ �� I � 1J�1 � 1 M�� Seria lNumber �� `-� Is the assembly installed in accordance with manufacturer recoirunendations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker DouUle Check Valve Asseinbly Relief Valve Air Inlet Clieck Valve 1 st Check 2nd Check �� Held at�'�psid Held at�•� psid Opened�t�•� O��ened at Held aY Initial Test Closed Tightl)Q Closed Tight !14 psid psid psid Leaked( I Leaked' I Did not open ' I Did not open ' ! Lealced' I Rep�irs/ Materials Used Held at psid Held at psid Test After Openaci at Openecl at Held�t _ Repair Closed Tight I I ClosedTight�1 psid psid psid Test gauge used: Make/Model II�il 1�- l 11 S T C�,� SN: �� V ( Date Tested for Accuracy: �� Remarks: The above is certified to be true at the time of testing. Firn�Nan�e / 1��'��5� Firm A ddress (�� '�" . S�.�� 5� ,1 �-�lc��TX-7G�`� Certified Tester(prfr�t) �� Cerrified Tester(si�llture) Firm Phone#� ��7-1 ^��5� Cert.Tester No.D r 0�� b�7� Daie � � ��p �� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS WhitE-City Copy Yellow-Custolner Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE The following form nllist be completed for each assembly tested. A signed and dated original must be sabmitted to t1�e public water supplier for recordkeeping puiposes: BACKFLOW PREVENTION ASSE��M��Y T�EST��D MAINTENANCE REPORT M. �'r' �> t � �P�� "��O � NAME OF PWS: CITY OF COPPELL PWS LD. #0570040 (Customer) n '/ u MAILING ADDRESS: �3� � � �`Y� � � t��. l.U bb�C-- l�-�� ' 7� `� CONTACT PERSON/PHONE: O 6 — — 3 6( LOCATION OF SERVICE: 2nk o� • CO The backflow prevention asseu�bly detailed below has been tested and maintained as required by connl�issiou regulations and is certified to be operating witl�in acceptable parameters. TYPE OF ASSEMBLY �.Reduced Pressure Principle 1-7Reduced Pressure Principle-Detector � I Double Check Va1ve I 1 Double Check-Detector I�IPressurcVacuumBreaker � 1Spi11-Resistant Pressure Vacuuin Breaker W ��t� S �0 - I Size ��02 �1 Manufacturer Model Number Located At �U ��i �� 'e'� �� Serial Nu�nber� � � �� Is the assen�bly installed in accordance witli manufacturer recommendatio�ls and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Asse►nbly Relief Valve Air Inlet Check Valve l st Check 2nd Check ��S� Held at�'�Usid Held at� � psid Opened at� Opened at Held at In�hal Test Closed Tight�4. Closed Tight �Q psid E�sid psid Leakedf I Leaked��l Dicl not opeu '� 1 Did not open ! I Leaked'�� I Repairs/ Materials Used Held at psid H�ld at psid Test After Opened at Opened at Held at Repair ClosedTight1l ClosedTight I psid psid psid Test gauge used: Make/Model�a�l n 5 � ��], J SN: �� V 1 Date Tested for Accuracy: �� 3�� fo Remarks: The above is certified to be true at the tiii�e of testing. Firm Name �� \ �S� Fiim Addresi � �b �"'� ' ��'�01 S� � K2..� ��1TK-7��'� Certitied Tester(pr:r�t) ��e'� Certified Tester(si��latw�e) Firm Phone# U �2��7 ^� 5� Cert.Testei-No.P �0�� 7� Date l� �lp '� t� �m TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-C=ity Copy Yellow- Custonler Copy Pink-Tester's Copy