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2016_1110 IRRIGATION V 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: �DO\ Q.-o5S al�ti S��.i1�e 2�� flo.��. `T�1�a� CONTACT PERSON/PHONE:� ,r��Sc� a-��-1c -alo'1-2S11��a� LOCATION OF SERVICE: t-Q�� s�� I .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 ❑Reduced Pressure Principle �7Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detectar ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker �� Manufacturer��y�c5 Model Number oa1 c�w�T Size�_ Located At�ac�a. �a� Serial Number Ss_��. � 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 a•� psid Held at�psi Opened at Opened at Held at Initial Test Closed Tight� Closed Tight psid psid psid Leaked':� Leaked❑ Did not open ❑ Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight❑ psid psid psid Test gauge used:Make/Model��,� �� SN: ��-�3 Date Tested for Accuracy: ��o� �. Remarks: The above is certified to be true at the time of testing. FirmNama�(1�� Firm Address Certified Tester(print) Certified Tester(signature) Firm Phone#�1`7��3�� Cert.Tester N�C�`1��el Date ��\d- 1\� * 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) MaIL�vG aDD�ss: 2�I �2os s �t �.��-1��.4ao ��S ,`�X 7.s�r CONTACT PERSON/PHONE: I — L - Y `� LOCATION OF SERVICE: �'g'g ,j, � v � 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 ❑R�duced Pressure Principle-Detector ❑Double Check Valve f�.Double Check-Detector nPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker r� Manufacturer L� t Model Number 1�C I�/4 � Size�_ Located At,S�[,�,1Y`u,,.�c t �r4 (/Q�•� Serial Number 000 t 7,S'I Is the assembly installed in accordance with manufacturer recommendations and/or local codes? G 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�psi Held at 3-d psi� Opened at Opened at Held at Initial Test Closed TightL. Closed Tight � psid psid psid Leaked❑ Leaked� Did not open ❑ Did not open �� Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model UV 1 a.G��1 �YS SN: �3OJ(�2�3 Date Tested for Accuracy: � '�o ' ( (o Remarks: The above is certified to be true at the rime of testing. Firm Name ��f� �l,i�,.j t�it'y �'�``�irm Address �'�Z.��.��QSS V(�Gf- ��csS,��j6�f4� Certified Tester(print) ' r Certified Tester(signature) �� Firm Phone# �� Z�� 7 3 d� Cert.Tester No. �, DDI 3,�o(llate ��—/Q - /(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 V 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) -A MAILING ADDRESS: a2o"�l �oss f�2 S.�c:�p�'POc� � Ckf� 7 Z�-D� CONTACT PERSON/PHONE: .•2I —oZ LOCATION OF SERVICE: '� The backflow prevention assembly detailed belo 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 ❑R�duced Pressure Principle-Detectar ❑Double Check Valve �)ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer ti- � Model Number 1�C(��' � Size o �� Located At N- �n,�w•�.�c i�- V�� Serial Number ObO�'S3 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 at3,g psid Opened at Opened at Held at Inirial Test Closed Tight� Closed Tight i� psid psid psid Leaked`:.I LeakedC' Did not open ❑ Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model 1�/�,�� p�/.S SN: a30_'�O�2 3 Date Tested for Accuracy: �—�o — 1 � Remarks: The above is certified to be true at the time of testing. FirmName��5 +�`^'�u��-Firm Address ( Gt/.��c.t' �V _ 1 k 767�f0 Certified Tester(print) � � s Certified Tester(signature) I Firm Phone# g 7��-��3�1 Cert.Tester No.�('00/3�-�O l Date � l'�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