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2016_1229 IRRIGATION V 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: 2�t"> ��k�� 5 y�� a (a� � CONTACT PERSON/PHONE: G,rQ ( �'(C/-- LOCATION OF SERVICE: S Q � I-r•�. r 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 ❑Red Pressure Principle f"lReduced Pressure Principle-Detector ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker '1Spi11-Resistant Pressure Vacuum Breaker � tr Manufacturer 5 Model Number� �/U� Yti � Size Located At� ��`1e 1� � h 4 c�' C.U�er•ia�l-�Fumber S y��' � 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 lst Check 2nd Check Held a� •o�psid �psid O ened at Opened at Held at Initial Test Closed Tight'�� Closed Tight �� psid psid psid Leaked❑ Leaked❑ Did not open C 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!J psid psid psid Test gauge used:Make/Model �. N SN:��)� �u)� y Date Tested for Accuracy: � "' '�-" Remarks: The above is certified to be true at the time of testing. FirmName ��CT��e_ �`"��irmAddress �US�ci L�'^( �-��•'� � � I1GS Certified Tester rint �` � Certified Tester si ature (p )IMv��,0. �� u� � ��, � Yh . Firm Phone# �� 1�l�� Cert.Tester No.��(�'.rJ(�'S�U 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 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: ��X� ��.L�•n✓��. ��R, S� I� ��a� �X CONTACT PERSON/PHONE: �' ! — � �' LOCATION OF SERVICE: Q �� 1' �v�- The backflow prevention assembly detailed below has been tested and maintained as required� commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY �Re�ed Pressure Principle ❑Reduced Pressure Principle-Detector f�ouble Check Valve ❑Double Check-Detector CPressureVacuumBreaker r1Spi11-Resistant Pressure Vacuum Breaker 2 1( Manufacturer �t/ri�. Model Number C�(/� tM � Size (� �+{� Located At �a�� erial Number �� 'SS Is the assembly installed in accordance with manuf cturer 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�ps' Held at�psid O ed 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 i-] Closed Tight❑ psid psid psid Test gauge used: Make/Model �•��1,f 21 1 �b�,� SN: �v�� Date Tested for Accuracy: S� ! �— � � Remarks: The above is certified to be true at the time of testing. Firm Name��'t�-�'��✓1 VZ -�%�'�--T-ii 11� A ddress 1 U�c�� ` �c1 �✓� (•�.S � ` (�J Certified Tester(print) ��V�� "�ified Tester(signature) �� Firm Phone# C�� a�1 � �� Cert.Tester No.R�W��C� Date �o�" �G^ ! 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 ariginal 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) �� \-n� `�1 ��,,� /�� '1 C� c 1�! MAILING ADDRESS: o� '1Cje� CONTACT PERSON/PHONE: G� r � �f U' 3 �. / LOCATION OF SERVICE: — � � e �l ��I 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 ❑R�e �d Pressure Principle-Detector ❑DoubleCheckValve C�ouble Check-Detector ❑PressureVacuumBreaker '-1Spi11-Resistant Pressure Vacuum Breaker �� " � (� Manufacturer Rv''�� Model Number Cr/�� 1/ Size Located At S • r� CG�e✓�' �01'' '�Serial Number AJ� ��6 � � 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 eld at�,,�'{psid Opened at Opened at Held at Initial Test Closed Tight Closed Tight , psid psid psid Leaked�� Leaked 7 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�7 psid psid psid Test gauge used:Make/Model 1 ' �'�J1�W e�� 0 � � SN: ��) ) �U � y Date Tested for Accuracy: �— �a �� Remarks: The above is certified to be true at the time of testing. Firm Name 1""'lT�'��a'lc¢ 't'�� Firm Address �G S�c-�I G�' '�( �'��'G`''� �41.a S Certified Tester(print)rnG'��0.�� ('`�✓"'�Certified Tester(signature) f '`� � Firm Phone# � �� 1�� Cert.Tester No.�Y�I�V i�Z�C� Date t �-'�'��t � * 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: �'� �" ��' l� �� ' /' CONTACT PERSON/PHONE: � 1 � ��" �� LOCATION OF SERVICE: 't" 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 ❑Re ced Pressure Principle ❑Reduced Pressure Principle-Detector oubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer I�. Model Number GtJ��a Size 3 f�_ Located At �- r � C(��(" �/w✓�� 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 1 st Check 2nd Check Held at�_�psid Held at��psid Opened at Opened at Held at Initial Test Closed Tight y� Closed Tight �� psid psid psid LeakedL'. Leaked�L! Did not open `_1 Did not open ❑ Leakedu Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i�l Closed Tight �l psid psid psid Test gauge used: Make/Model n'1•�l.�a� �6�t 1 SN: �(�1 �/(� /� Date Tested for Accuracy: �i–`� '–� � Remarks: The above is certified to be true at the time of testing. FirmName f�"��'r�wl�¢ �•�—Firm Address �U�o1 � ��n c ��, I�+^�. � (�aS Certified Tester(print) l, ��a��. 1�1��•cvW`Certified Tester(signature) � '�/ Firm Phone# a �� 7�k � Cert.Tester No.��Grir SITC� Date� oZ�.R'��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