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2016_1014 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 supp(ier 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: n� � �,,�,,,�.4 /7- �-��_ ,r?ys,,[q LOCATION OF SERVICE: //f�� ;,�,,� � The backflow prevention assemb}y detailed below has been tested and maintained as required by commission regii(ations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY =;Reduced Pressure Principle ❑Reduced Pressure Principle-Detector E=lDoubleCheckWalve �ouble Gheck-Detector �--iPressureVacuumBreaker �!Spill-Resistant Pressure Vacuum Breaker Manufacturer Gt�e+:�� Model Number ��9 G�cG(cr` Size O Located At �� Serial Number l�Ci��-�� 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 �� 8 psid Held at3' �psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leakedi��l LeakedCl Did not open ��:�; Did not open '��,' Leaked�� i Repairs/ Materials s Used Held at__psid Held at psid Test After -Opened at Opened at Held at Repair ClosedTight��_�a Closed Tight�`i psid psid psid Test gauge used: Make/Model t,(/j/��/S �� 'S SN: 070 90��_ Date Tested for Accuracy: �-9- // ` Remarks: The above is certified to be true at the time of testing. Firm Name__i�� ,c� -�jD�! Firm Address �v'�� ,�`� 7SibcF' Certified Tester(print)�,,...c'Fl� �r Certified Tester(signature) Firm Phone# ��°-S'SO' �-�� Cert.Tester Nd�p v�a �/�' � Date /O—/�-/� * 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 originat 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: v ,� �,�,,,4 /7. 3-1�_ ��fl� LOCATION OF SERVICE: //// EYe�w7�v�e The backflow preventian 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 �.�Reduced Pressure Principle-Detector �ffloubleCheckValve 'Double Check-Detector '-!PressureVacuumBreaker !Spill-Resistant Pressure Vacuum Breaker Manufacturer /�Ja� Model Number ��/s11 Size �� Located At �� 1�� V Q,c.�� Serial Number (�,��a,�-a Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuurn 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� Closed Tight I� psid psid psid Leaked"�� Leaked❑ Did noC open :�i Did not open '��; Leaked:�J Repairs/ Materials e Used Held at psid Held at psid Test After -Opened at Opened at Held at Repair Closed Tight'�J Closed Tight�-1 psid psid psid Test gauge used:Make/Model /,�/�/��_��-S� SN: p7�90� �_ Date Tested for Accuracy: _ �-9-�/ • Remarks: The above is certified to be true at the time of testing. Firm Name_�� ,�2 �Firm Address �_� �'T7 �� ,'T`� 7Sibc�1' Certified Tester(print) �N.•c� �� Certified Tester(signature) ��-� �/" Firm Phone# ��-S°SO' �'��7 Cert.Tester Nd$p v�a 6/_S �Date /O-f�f-/� *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 �F COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: � � �,,�,�,,,4 /7- ?�/- v9r.�9 LOCATION OF SERVICE: ///1 E!�-er�r.��,v-�t 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 �+'�auble Check Valve Double Check-Detector '�7 Pressure Vacuum Breaker ^',Spill-Resistant Pressure Vacuum Breaker ^ � , � ,i Manufacturer l/�/ Modei Number OD'�Y�{J Size Located At �r�he��/ (o'� @ �� Serial Number_ 2 S I S 1 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Brealcer 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 Tighti�� Closed Tight 1"� psid psid psid Leaked"[�i LeakedCl Did not open ��1 Did not open -:�1 Leaked� '� Repairs/ Materials s Used Held at psid Held at psid Test After -Opened at Opened at Held at Repair ClosedTight':_:! ClosedTight[ i psid sid p psid Test gauge used:Make/Model /�j��s �� "S SN: O?'O 90��_ Date Tested for Accuracy: �,-g-�l� • Remarks: The above is certified to be true at the time of testing. Firm Name � �,e.� �2/2u' Firm Address �v�,�,� ?�T'7 ��, _J]"�l 7SibZ� Certified Tester(print)�.,.•�c'1� �� Certified Tester(signature) ��C�-w" ��-- Firm Phone# ��-SSO' y�'�`7 Cert.Tester No'�P vDa 6/S `� Date /O-l�-/� *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 Y 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 PREVENTIOIv ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. #0570040 (Customer) MAILING ADDRESS: CONTACT PERSONCPHONE• v � � �,,�,,,�.y /7- -�/- ,(��i� LOCATIO�N OF SERVICE: f1// �X-e��,c.Tiuc2 The backflow prevention assemb}y detailed below has been tested and maintained as required by cammission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY �1 Reduced Pressure Principle '=7 Reduced Pressure Principle-Detector �Double Check Valve ';'Double Check-Detector �7PressureVacuumBreaker _��:Spill-Resistant Pressure Vacuum Breaker ,r Manufacturer � Model Number C'1CC�''J �� Size � Located At M7�t1 - /� .�� Serial Number 2r�� Is the assernbly installe in accordance with manufacturer recommendations and/or local codes? �.✓ Reduced Pressure Princi le Assembl Pressure Vacuurn Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve ]st Check 2nd Check Held at �' psid Held at �'� psid Opened at Opened at Held at � Initial Test Closed Tight�� Closed Tight� � psid psid psid Leaked[ 1 LeakedCl Did not open - 1 Did not open 1 i Leakedi ! Repairs/ 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 Test gauge used: Make/Model �,C/��jr,/5 �� "S SN: O7�90��_ Date Tested for Accuracy: ��q-// ` Remarks: The above is certified to be true at the time of testing. Firm Name fy� �,�.� �jTlt° Firm Address��"7T7 � �,7�, 7S�b8 Certified Tester(print)�ti�� s✓ Certified Tester(signature) Firm Phone# ��-S'SO' 7-'��'7 Cert.Tester Ncf�p c»a !S � Date /O—,/�-/� *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