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2016_1107 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) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: �4 _ 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 �r1R�e uced Pressure Principle ❑Reduced Pressure Principle-Detector l�"DoubleCheckValve ❑Double Check-Detector �PressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker Manufacturer LGc Y�f�- Model Number /.SO �'�Z. Size 3�� Located At 9�b 1�, j�� Serial Number .3�� / �� 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 ,'� ps Opened at Opened at Held at Initial Test Closed Tigl� Closed Tight� psid psid psid Leaked❑ Leaked❑ id not open Cl 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 fic��✓i," �E7 .� SN: c�-'�o�L�� Date Tested for Accuracy: �-' fi�� Remarks: The above is certified to be true at the time of testing. FirmName iQC�ca,... �/�Z. �S Firm Address ��'�y7 In�c�� i, �Z$(6� Certified Tester(print) ,�„�,�� Of3.�,.�Certified Tester(signature) ��r...,.�1/L- Firm Phone#�L�-��,�- �� Cert.Tester No.��c9,�.�. (�iS��ate 1 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 Y 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) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: The backflow prevention assembly detailed below has been tested an 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 ❑Double Check Valve �ouble Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �c/��i�.- Model Number �� ,/4�"]��Size� Located At�1(�, 1'v � ��.c.tJCJ� Serial Number �� / � 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 ]st Check 2nd Check Held at 3 '�psid Held at ��psid Opened at Opened at Held at Initial Test Closed Tigh� Closed Tigh 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 °v✓��w— � SN: C7��'�� Date Tested for Accuracy: fo� ��J � Remarks: The above is certified to be true at the time of testing. FirmName f'1G�,c,a,,.� f 1'�.T tVt�Firm Address��y� ��.-. T�-� �s r�� Certified Tester(print) �-'CZ �.:x'�-� Certified Tester(signature)�. Firm Phone#�� 'Q� Cert.Tester No.�ivo�� 1S7 Date /I- `7� �� * 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: CONTACT PERSON/PHONE: LOCATION OF SERVICE: � , w,,,,�.�+., � The backflow prevention assembly detailed below has been test d 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 T �,� Model Number �.�7� Size � Located At 7.S�,sth �a��i�,:-�.�, ��Serial Number �l ��'S �`-1 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�psi Held at �' �psid Opened at Opened at Held at Initial Test Closed Tigh � Closed Tight � psid psid psid LeakedCa 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 i 7 ClosedTight❑ psid psid psid Test gauge used:Make/Model w��`^�+-� ��i.� SN: O'7�°� �'�' � Date Tested for Accuracy: �" � � (� Remarks: The above is certified to be true at the time of testing. FirmName �� Q. t�'�c�S Firm Address �G' � 7�7 G�V� �il '7,�/�'o� Certified Tester(print) ��,,,,�,��Certified Tester(signature) , �� FirmPhone# C��J—e'L�`7 Cert.TesterNo.�,��fca5`� Date �/�'7-/� * 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: CONTACT PERSON/PHONE: LOCATION OF SERVICE: � -� The backflow prevention assembly detailed below has been tested an maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY �f 1 duced Pressure Principle ❑Reduced Pressure Principle-Detector oubleCheckValve ❑Double Check-Detector i-lPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer !N� Model Number f�� i �'L'+1 Size Z Located At N,�1E�, �rr,... �� L��'/��erial Number �� 0 7�' 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 � O Held at r �psid Held at� 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❑ 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 L'-'��. � , SN: D ��!�� Date Tested for Accuracy: �—��j�, Remarks: The above is certified to be true at the time of testing. Firm Name �j �� 2•.Q �l/l3.� Firm Address�c�o,U ?�I7 G�I •.ti.� J�, '7 S'�f�� Certified Tester(print) ,� , � � ertified Tester(signature)�/��c�.C.C.. Firm Phone# ��',��r7 •`�2 d / Cert.Tester No.��c� �'IS� Date �� '� �G *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