Prologis Park-LR170111IRRIGATION 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: P,,1
CONTACT PERSON/PHONE:
LOCATION OF SERVICE:
I
u 1-1 Cu-Wy uA �Z H�� � )c, I 1,iT>c
7-z-- tc8'y-C; zSZ
.of—
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 El RS ced Pressure Principle -Detector
[]Double Check Valve e5ouble Check -Detector
[]Pressure Vacuum Breaker 11 Spill -Resistant Pressure Vacuum Breaker
Manufacturer Lj c I �1 ^I Model Number������� �-+� Size
Located Ati ag I� Sw cotv%*_.-* J/'oNiA-y Serial Number
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? c-.jL
Test gauge used: Make/Model W , ` SN: 0 f ( 1 6 9 tS
Date Tested for Accuracy: &, CD ' L 16
Remarks:
The above is certified to be true at the time of testing.
Firm Namel',xil0&4j"' Firm Address '"60kX38
Certified Tester (print) tr— vQ & Certified Tester (signature) Mle)C.C3, ►oI�^
Firm Phone # Cert. Tester No. �Piq-�5Date /—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
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1 st Check
2nd Check
Held at LAf psid
Held at/. (V psid
Opened at
Opened at
Held at
Initial Test
Closed Tight
Closed Tight
psid
psid
psid
Leaked❑
Leaked[]Did
not open F1Did
not open F1Leaked[]Repairs/
Materials
Used
Held at psid
Held at psid
Test After
Opened at
Opened at
Held at
Repair
Closed Tight El
Closed Tight1-1psid
psid
psid
Test gauge used: Make/Model W , ` SN: 0 f ( 1 6 9 tS
Date Tested for Accuracy: &, CD ' L 16
Remarks:
The above is certified to be true at the time of testing.
Firm Namel',xil0&4j"' Firm Address '"60kX38
Certified Tester (print) tr— vQ & Certified Tester (signature) Mle)C.C3, ►oI�^
Firm Phone # Cert. Tester No. �Piq-�5Date /—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 v
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: Pro Los S 'L. Q I /j Mu,,wwuol 'h-2.YS-a 13cd1-_tT�d 7 T -LQ (
CONTACT PERSON/PHONE: 7 'Z - r 8' - 9 Z 9 Z
LOCATION OF SERVICE: 41(.5 AJ I--Pc-e a jr- - twy
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
❑DoubleCheckValve P�ouble Check -Detector
❑ Pressure VacuumBreaker ❑Spill -Resistant Pressure Vacuum Breaker
Manufacturer LJ c I,$ Model Number 7> 0 X <-b Size 3/y
Located ANQti �� Ge.^ i u%,jr, c.,, Serial Number �{ 2 �� 2- (� CA(
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?y e S
Test gauge used: Make/Model W41(11^ SN: dl 1 % c (713
Date Tested for Accuracy: 6-(o - /
Remarks:
The above is certified to be true at the time of testing.
Firm Name AD4L4 to &04<T&/ Firm Address P(% int k 3lilM 0,7
Certified Tester (print) Y [ (�K MeO 0AW Certified Tester (signature) e. a - d
Firm Phone # � 14---- yo -D& Cert. Tester No. 6 PJIxS
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
Date 1-t/-/'7
White- City Copy Yellow- Customer Copy Pink- Tester's Copy
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1 st Check
2nd Check
Held at/. 3 psid
Held at /• 7 psid
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
Closed Tight ❑
Closed Tight ❑
psid
psid
psid
Test gauge used: Make/Model W41(11^ SN: dl 1 % c (713
Date Tested for Accuracy: 6-(o - /
Remarks:
The above is certified to be true at the time of testing.
Firm Name AD4L4 to &04<T&/ Firm Address P(% int k 3lilM 0,7
Certified Tester (print) Y [ (�K MeO 0AW Certified Tester (signature) e. a - d
Firm Phone # � 14---- yo -D& Cert. Tester No. 6 PJIxS
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
Date 1-t/-/'7
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: P/'u4"AS tj WQ&^wu 0d b—ZY,'- t1 pe. ( Iar7�y7S Z,
CONTACT PERSON/PHONE: -7 2 If 9 2
LOCATION OF SERVICE: 9_/5 /\% �_ fC `� y
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
❑DoubleCheckValve ?6o"uble Check -Detector
❑ Pressure Vacuum Breaker 11 Spill -Resistant Pressure Vacuum Breaker
Manufacturer W .' )G1Model Number -S -5 J !TS rQAize V
Located AtM&A L03 carH e✓ 03, ,pood7Serial Number Ct 3 13
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y .t
Test gauge used: Make/Model SN: d 1 t l 699
Date Tested for Accuracy:
Remarks:
6,10 —/ 16P
The above is certified to be true at the time of testing.
Firm Name V Ud Address � &X 31313 7 T j Z-/ 3,00
Certified Tester (print) l °( 20 v�CrB Certified Tester (signature) �c.
Firm Phone #d,14410 1 -4774, Cert. Tester No. ft4;�( 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
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1 st Check
2nd Check
-^d
Held atpsi
Held ata psid
Opened at
Opened at
Held at
Initial Test
Closed Tighit
Closed Tight Npolfpsid
psid
psid
Leaked[]
Leaked[]
Did not open ❑
Did not open ❑
Leaked[]
Repairs/
Materials
Used
Test After
Held at psid
Held at psid
Opened at
Opened at
Held at
Repair
Closed Tight ❑
Closed Tight ❑
psid
psid
psid
Test gauge used: Make/Model SN: d 1 t l 699
Date Tested for Accuracy:
Remarks:
6,10 —/ 16P
The above is certified to be true at the time of testing.
Firm Name V Ud Address � &X 31313 7 T j Z-/ 3,00
Certified Tester (print) l °( 20 v�CrB Certified Tester (signature) �c.
Firm Phone #d,14410 1 -4774, Cert. Tester No. ft4;�( 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 V"', 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: Pro f ,�Q 13 14ct a L,a cj a d'ZYSQ 7) ZQ
CONTACT PERSON/PHONE: 417 L — & r y - 9 9 ?—
LOCATION OF SERVICE: F r e.Q Jv,,r- —11
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
[I Double Check Valve Ctlo�uble Check -Detector
❑PressureVacuumBreaker ❑Spill -Resistant Pressure Vacuum Breaker
Manufacturer 1c j yo, Model Number -S :5'0 At SIVAr Size $'
c O., j�e.?
/�Gj--.,-
Located At \ %4A C t... �-e a)1' 614!% Serial Number :o % y r3
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ,V t �
Test gauge used: Make/Model IV i-rS .-1-K r? -( E�, SN: (g
Date Tested for Accuracy: G — (o —f
The above is certified to be true at the time of testing.
Firm Name V0.1/1 °(�Qli� °( .1-tPJ irm Address `PV &K Sia R 7 DOROO �UyI��{s, %�C 6130
<
Certified Tester (print)(A Certified Tester (signature) �` t.���Zcar..��✓
Firm Phone # 40 I -4%7Cert. Tester No. CJ PS S�(o 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
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve
Air Inlet
Check Valve
1 st Check
2nd
2nd Check
Held at, O psi
Held at ! • 5,
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
Test After
Repair
Held at psid
Closed Tight ❑
Held at psid
Closed Tight ❑
Opened at
psid
Opened at
psid
Held at
psid
Test gauge used: Make/Model IV i-rS .-1-K r? -( E�, SN: (g
Date Tested for Accuracy: G — (o —f
The above is certified to be true at the time of testing.
Firm Name V0.1/1 °(�Qli� °( .1-tPJ irm Address `PV &K Sia R 7 DOROO �UyI��{s, %�C 6130
<
Certified Tester (print)(A Certified Tester (signature) �` t.���Zcar..��✓
Firm Phone # 40 I -4%7Cert. Tester No. CJ PS S�(o 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