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2017_0111 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) , � r 1� ., � � MAILING ADDRESS: �/v�-'Oy I1 Z�u � /" �c'�'�"�""� ZH� � C•I Ic�sT� 7�Z � CONTACT PERSON/PHONE: cI'�'Z-- tC 8'll—S Z-'`''+ Z- LOCATION OF SERVICE: �-/t�� N l�r�-✓•�� ) �c.�-•� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within..acceptable para�neters. � TYPE OF ASSEMBLY 'Reduced Pressure Principle Re ced Pressure Principle-Detector �� Double Check Valve ouble Check-Detector IPressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer �e � ��1 Model Number Q��!:�C �+� Size �� Located At�'a.� �1- Sw Go/`�� J/'o1��'y Serial Number �2� Z4tq 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�. � psid Opened at Opened at Held at Initial Test Closed Tight. ' Closed Tight � psid psid ps�� Leaked` � Leaked � Did not open Did not open �� Leaked �I 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 �t�6�7�� SN: �f u �''"' t� Date Tested for Accuracy: (�--L� ' l � Remarks: The above is certified to be true at the time of testing. Firm Name '1-�J�►i�� 1��`l`�� Firm Address �O�NX��" ��`��..y��c.�� Certified Tester(prtr,t)��- ��Certified Tester(signature) ��e��►�''"�� Firm Phone# ��-�a �-4��1�f Cert.Tester No. �r��`�`� Date �-1 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 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) MaILrNG aDD�ss: I��o Los :s 2�� r A7 HG.��..��d ''`'zYr� I��tl•.s1'� 7�� CONTACT PERSON/PHONE: 7 Z• � g - Z 9 Z- LOCATION OF SERVICE: �-! (, N r/'ct �+v�� Cw� 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 ❑Double Check Valve �ble Check-Detector i IPressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �c � �•�3 Model^umber �� X�-.V Size 3�Y )—r��c�� Located AtvGt,�•i,�� Ge.��i u.�- �l�l� v r.. Serial Number L{Z y Z (� c�9' Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held atl•3 psid Held at �• 7 psid Opened at Opened at Held at Initial Test Closed Tight'��1� Closed Tight :� psid psid psid Leaked� Leaked��;.'� Did not open ❑ Did not open '��1 Leakedn 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 �� T(GCj�(� SN: (�� / t��1 g Date Tested for Accuracy: �—� � �/� Remarks: The above is certified to be true at the time of testing. Firm Name �1�1iC(�1 c� �C°-�'t��u,/ Firm A ddress t�� ,3`��3 0�-7 �,/UL1 C�t;t 1�vr��TX /�/3�, Certified Tester(print) �� '��CCt�n�t✓ Certified Tester(signature) v �- e •-�./ Firm Phone# ��}�p►-�f�7�f Cert.Tester No. �PS�S(p 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) y� MAILING ADDRESS: �/'u�iS ZSv� /l� �a�t..x��d( ZY�� c.I I arT�7�Z� / CONTACT PERSON/PHONE: �i 7 L� !� •�I' L 4 2 LOCATION OF SERVICE: Y /,� /� l�'/►te ��•» �- I��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 ❑Double Check Valve �uble Check-Detector ❑PressureVacuumBreaker �'Spill-Resistant Pressure Vacuum Breaker Manufacturer (.�,J � � �-+� Model Number � �J �S��/'15ize g Located At1/[t�.�� ..� CprH e✓ c�� ,C��o�'7Serial Number � (� �313 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? .t J 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 -�^psid Held at3�psid Opened at Opened at Held at Initial Test Closed Tight��. Closed Tight � psid psid psid Leaked❑ Leaked�� Did not open !� Did not open n Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight f 1 psid psid psid �' " � Test gauge used:Make/Model 1,v�S 1�`?�I C SN: d 1// �o�/ �i Date Tested for Accuracy: �� "� � Remarks: The above is certified to be true at the time of testing. FirmName f�-�'�� C�.K,��Firm Address�� /3�7 �I��R�►��(G /,��j3a —�. . /�� Certified Tester(print)��'C.�, �PaCG�Certified Tester(signature) ��– /'��.�,�„� Firm Phone# o��–g0 � ��7� Cert.TesterNo.��-S� Date 1 � ��' /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 IRRI6ATION 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) Ma1Lnv�aDD�ss: ��o�x �.i Z��t N t-l4,��..o�d a'ZY'S� � , 1��.1 �� 7��-�'� CONTACT PERSON/PHONE: �I�L— - 4 '^�' '_- LOCATION OF SERVICE: ! I'tQ vr wV 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 �1Reduced Pressure Principle �'Reduced Pressure Principle-Detector �DoubleCheckValve I�uble Check-Detector ❑PressureVacuumBreaker 7Spill-Resistant Pressure Vacuum Breaker Manufacturer �� u•.3 Model Number � �� /'�Sfiu/fi Size g Or� �i�t��r�.�' Located At�/'�� C t..�-�� a�- h I��._Serial Number �o � c7 y l� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ,V t t Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held a��O psi Held at�•�psi Opened at Opened at Held at Initial Test Closed Tigh� Closed Tight� psid psid psid Leaked' I Leaked� Did not open ❑ Did not open f 7 Leaked�1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight Cl Closed Tight❑ psid psid psid Test gauge used:Make/Model j,(/l�'�5� �?-t� SN: �� Date Tested for Accuracy: 6 ��o"/� Remarks: The above is certified to be true at the time of testing. FirmName �110.�1,C°�Q� �C(��irm Address pd OEJx �v��3�7 �41�{lNl�'I��G,� 1��3C� Certified Tester(print)��'�a��'�Certified Tester(signature) .. t o�� Firm Phone# ��'��l��77� Cert.Tester No. �C,J�S� S,�_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