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2016..1010 IRRIGATION DOMESTIC FIRELINE The following farm must be completed for each assembly tested. A signed anci dated original must be submitted to the public water supplier for recordkeepin purpose � �o• �f �fi S�• ��0 � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) �f,�, 2� � � �`Y1 � � ��. �U bb'�C� l�-��. • 7 I le�-3 MAILING ADDRESS: V cJ CONTACT PERSON/PHONE: O � — ' 3 6 I LOCATION OF SERVICE: Z!�-�r v� • �0 The b�►ckflow prevention assembly detailed below has been tested and maintained as required by convnission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ��Reduced Pressure Principle I�Reduced Pressure Principle-Detector �Double Check Valve ��Double Check-Detector ! IPressureVacutm�Breaker �1Spill-ResistantPressure VacLiumBreaker 1 ` �� Manufacturer �� Model Number O � � Size /�' Located At � '� �U�S �k �'�� Serial Numbei��t"� 1 O� � „n is t11e asse�nbly uistalled in accordance with nlanu acturer recomiuendations and/or local codes? � Reduced Pressiu•e 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�t�'� psid Opened at Opened at Held at Irtitial Test Closed Tightl� Closed Tight ?� psid psid psid Leakedf I Leaked�I Did not open �� 1 Did not open ! I Leakedl I Replirs/ Materials Uscd Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight� l ClosedTight� I psid psid psid Test gauge used: Make/Model 11�a 1�--i 11 5 � l�,� SN: �� I�� Date Tested for Accuracy: � � �� Remarks: The above is certified to be true at the titne of testiiig. Firm Name ��'��5� Fii7n Addres1 � �� "� . s�'�o1 S� � �..` ��1�K-7L� Certitied Tester(pr:alt) ��e'� Certified Tester(signature) Firin Phone# D �2��7 ^� 5� Cert.Tester No.P �"�� b�701 Date � � ��p'� t7 * TEST RCCORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White- City Copy Yellow-Custonier Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE� The following forn� inust be co�npleted for each assembly tested. A signed aud dated original must be submitte�d to the public water supplier for recordkeeping puiposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS 1.D. # 0570040 (Customer) f� Q (' 0� � O ��e.. �U bb'�C��. • 7� `�� MAILING ADDRESS: •�V 3� h CONTACT PERSON/PHONE: O 6 — — 3 6I LOCATION OF SERVICE: 2�k a � • CO Tlle backflow preventioil asseu�bly detailed below has been tested and maintained as required by comil�issiou regul�tions and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY i 1Redliced Pressure Principle I�Reduced Pressure Principle-Detector `�.DoubleClleckValve '��1Double Cl�eck-Detector I�IPressui-rVacuunlBreaker ��-iSpill-Resistant Pressure VacLium Breaker Ir 3/ �, Manufacturer W �"�k � Model Number OO �►M � Size y Loc�ted At ��U � ��L� ��h��Serial Number � � � � � � Is the asseinbly installed in accordance with inanufacturer reconm�endations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker DouUle Check Valve AssemUly Relief Valve Air[nlet Clieck Valve 1 st Check 2nd Check �� Held at �'� sid Held at�' � psid Opened at Opened at Held at Initial Test Closed Tightl , Closed Tigl�t � psid psid psid Leakedf I Leakedl I Did not open '� I 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 Closed Tight� ] Closed Tight f I psid psid psid Test gauge used: Make/Model�a 1�- i/1 S T ��,� SN: �� V 1 Date Tested for Accuracy: � �3�� Remarks: The above is certified to be t��ue at the time of testiilg. FirmName �1��5� Firm Address � �� ^�"� . S'��o1 S� � K2.��C�JTX-7G�� Ccrtified Tester(pr;nt) �� Certified Tester(signature) Fir►n Phone# D ��J 7"1 ^��S� 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 Wlute-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC FIRELINE The following forn� must be complete�d for each assenibly tested. A signed and dated original must be submitted to the public water supplier for recordkeepin�ptuposes: BACKFLOW PREVENTION ASSEMBLY T ST ND MAINTENANCE REPORT f�.e�l'l�� e� �- 5� �f NAME OF PWS: CITY OF COPPELL PWS 1.D. # 0570040 (C�istomer) �f Q (� D� � O �U �b'OC��. • 7� �a2� MAILING ADDRESS: r> V �� Y1 �� CONTACT PERSON/PHONE: O 6 — — 3 6( LOCATION OF SERVICE: �n-�r o� • �0 The backflow prevention assembly detailed below has been tested and u�aintained �s required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY f iReduced Pressure Principle I 1Reduced Pressure Principle-Detector 1�Double Check Valve ��1 Dotible Check-Detector I I Pressure Vacl�utn Breaker �-I Spill-Resistant Pressure Vacuum Breaker - ( C �J I� Manufacturer N L�� J Model Number� � ( Size� Located At �1� U �� Ip aG� Q�'�"'�B`'�C� Serial Number � � —� �� r Is t1ie asseinbly installed i�i accordance with manufact�uer recotrvilendations and/or loca] codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assetnbly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check � � �� Held at�psid Held at�'� psid Opened�t Opened at Held at Inirial Test Closed Tight�Q Closed Tight 1� �sid psid psid Leakedi I Leaked'�I Didnot open '� I Did not open I I Leakedl I Replirs/ Materials Used Held�t psid Held at psid Test After Opened at Opened at Held�t Repair Closed Tight I_1 Closed Tight'�I psi� psid psid Test gauge used: Make/Model�� i11 S � �],� SN: �� l Date Tested for Accuracy: � �3�� b Remarks: The above is certitied to be true at the tiTne of testing. FirmName ��'��5''C Firm Addres` � �� --�`� • c5a''�,�� S� � �-` ��1�K-7G�'� Certitied Tester(}�r;r�t) �� Certified Tester(signature) Fii-�n Phone#� ��J 7q '� 0 S� Cert.Tester No.P �0�� b�701 Date �� p 'I t7 * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-C ity Copy Yellow- Customer Copy Pink-Tester's Copy