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2016_1110 (2) 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: �A�� S { .SK� Oc7 V X 7 CONTACT PERSON/PHONE: �/ '�L - �^ LOCATION OF SERVICE: o 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 �II�educed Pressure Principle ❑Reduced Pressure Principle-Detector C�ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer t J"�Prt'5� Model Number �Q L Size 3�7 Located At �- C�1��kn c� ��-'1��7'' Serial Number 9/ 1�� r Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? 25 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 a'1•8 psid Opened at Opened at Held at Initial Test Closed Tight:� Closed Tight � psid psid psid Leaked❑ Leaked'�] Did not open ❑ Did not open [-1 Leaked��l 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 YY IaG�� g`�.s sN: d 3bSo 2� 3 Date Tested for Accuracy: �"'(o' ��i Remarks: The above is certified to be true at the time of testing. FirmName ��rttLil-<-J(N-k�y �'"�"'"�`F'irmAddress2�,2.� l(� �-c.l'�f �I��.T��(j Certified Tester(print) ��G� �b f Certified Tester(signature) � Firm Phone# �l-�'7��Z;��'9��rt.Tester No. ��DO(3�6 / Date � � (� ^.�b * 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: O � 5 L Dc� s t j� CONTACT PERSON/PHONE: 2/ 'a•?b - LOCATION OF SERVICE: _ o 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 ❑I�educed Pressure Principle ❑Reduced Pressure Principle-Detector C�3'j�ouble Check Valve C iDouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �1 � 1 1�-��n 5 Model Number ��a X �- Size�_ Located At S Fiin-�-Yw�c c ��,�1 tl-tr �o�_Serial Number �l.S,�� 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 3��"psid Held at3•� psid Opened at Opened at Held at Initial Test Closed TightC� 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 i�o►(,1C1',�� O�.s SN: (�30� Z 2 3 Date Tested for Accuracy: � ' (o ' ( � Remarks: The above is certified to be true at the time of testing. Firm Name��`J't F�y'I..c ��-L�-� (�""'��'irm A ddress��lt�,�ic,t",��j�V��.�s—��O��( Certified Tester(print) � t' �`O S Cerrified Tester(signature) Firm Phone# '7�o�-0�2`1�`7 3 0 � Cert.Tester No. R Pd01��.(�9 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 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: OJ l� s �,3.20 CONTACT PERSON/PHONE: �1 ' - D LOCATION OF SERVICE: g 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 �❑R duced Pressure Principle ❑Reduced Pressure Principle-Detector oubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker c� Manufacturer fS Model Number F Q L Size 3/`� �— Located At,S. ��fra,r.�� iw (/�n�LT Serial Number ��, i��,� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �ES 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 Opened at Held at Initial Test Closed TightC� Closed Tight C� 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�o.L(�+r� `�'�.� SN: (Z�C��a 2�3 Date Tested for Accuracy: y�(.-� � Remarks: The above is certified to be true at the time of testing. Firm Name�;r�F�c'�t. .5�4-FL� ��'�Firm Address�'gZ� �/-��Y�CfS ��✓d'-,�c.(��s,��' 7�� Certified Tester(print) �� Certified Tester(signature) �� Firm Phone# 5 7�-2�'�- q 3�� Cert.Tester No. (,��0�13 2(r`j Date � �� _r� * 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