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2016_1111 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) 1 MAILING ADDRESS: � S c�,` (--G�.�.-� CONTACT PERSON/PHONE: r' 5 c � 4.•ti�t- LOCATION OF SERVICE: Ct)n[a9-G�- vC�Le.� �.� S r��-f- 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 �poubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer l..✓ � ( �lrK� Model Number � �d Size � �� Located At �C��C�c�� l)ed.1� C�G�a-�� Serial Number �� S Is the assembly installed in accordance with manufacturer recommendations and/or local codes? I�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 at�psid Opened at Opened at Held at Initial Test Closed Tight�. Closed Tight �G' psid psid psid Leaked'� Leaked❑ Did not open n Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight r7 Closed Tight❑ psid psid psid Test gauge used: Make/Model /�,00`�b y/.Zec)��U SN: U!/�/,Z�� %L Date Tested for Accuracy: _ ��C�� — �� Remarks: The above is certified to be true at the time of testing. FirmName --�"`-�/�`�-� �i � Firm Address /�� (�.. /�l �� 'C / JC� Certified Tester(print)C,�, ��ovd�Certified Tester(signature Firm Phone# C�� "t.02.-�� cf�..�� Cert.Tester No. C�/��g � Date 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 FIRELINE f C 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) /A/ MAILING ADDRESS: �3 d Ss �O�({/1 `j'` � ��(//✓t�/��_�X CONTACT PERSON/PHONE: i�.1.a� y C�� LOCATION OFSERVICE: 37� S� ,��c, C Lh 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 �oubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer��E I f�i�S Model Number ��L Size �� J � � � � ��7�� Located At tJCt�t� � IJC.G� �jvL Serial Numbe Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �'e 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 1.9 psid Held at�.d psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight �� psid psid psid Leaked❑ Leaked❑ Did not open �l 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 L psid psid psid Test gauge used: Make/Model /+,08�� y�/��r��<�U SN: � f`' 1 ��- Date Tested for Accuracy: ��-(�7— /6 Remarks: The above is certified to be true at the time of testing. Firm Name �a��4-� �r�t_ Firm A ddress �� .t�� 4-y�'G�d' �� CertifiedTester(print)S�.��t�.�„`� �o�C�3�<CertifiedTester(signature) Firm Phone# ��'� ��U Cert.Tester No. G�r�� Date ` !I ��✓�" * 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: CS --S,� ; G. L � — C� �� CONTACT PERSON/PHONE: 'z C�,'�-v� LOCATION OF SERVICE: �,7G S� e c.�� L� 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 1Reduced Pressure Principle �educed Pressure Principle-Detector i�DoubleCheckValve �Double Check-Detector nPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker ' !�,+ 1� Manufacturer (,�. �lG�N-� Model Number � � � � a- Size cJ Located At��..�.C�'G'fe ISG..v,.�� /`�(J G Serial Number �� d �� 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�psid Held at Z.(� psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked[l LeakedCl 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 r�%C� ��X r� ��1�6 SN:_�}/�� - Date Tested far Accuracy: ��'(��` �cS �� Remarks: The above is certified to be true at the time of testing. FirmName ��-� �� Firm Address �� t � �r.�C� � �C�� Certified Tester(print)/.�>, ��-� ��ertified Tester(signature � Firm Phone#�j �Z�'� /�-S� Cert.Tester Na �j��/ 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