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2017_0120 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) ��'��f� MAILING ADDRESS: S�� E:SZ� 3`.� z� � itr.� � ��- 3 8 3� CONTACT PERSON/PHONE:�w�-��.�s- 1' ��g"Z- ��f— �� LOCATION OF SERVICE: � �-- Z o � ' r • The backflow prevention assembly d tailed below has been tested and maintained as quired by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �c�-f� s Model Number �`7��./� 0� Size ��, Located At P��- � 5 ��r�� l-t�-�--�` Serial Number %�°S'�4��0 ° � Is the assembly installed in accordance with manufacturer recommendations and/or local codes? 'Z� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check �r�f Held at psid Held at�'�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight psid psid psid Leaked❑ Leaked' I id 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 /�r��v��" ��S-�' SN: c� �l c('�i G3 � � Date Tested for Accuracy: !'�"lI —l6' Remarks: �c�-7'�S� The above is certified to be true at the time of testing. Z 3�S, P, / v' �S� S�j�h��-b��r. �°�'` �il�G4-r-��I� frt�.� FirmName Firm Address `- ;H�� 75�GS� 7— Certified Tester(print) � Y-o � �ertified Tester(signature Firm Phone# ��(� �v 3�'� �S�ZCert.Tester No�/�o�/��$ `� Date ,�- Zo' Z �f � *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) �� MAILri•i�aDD�ss: 5�� les � — 20/N a;w � 7s�� —3:3�5� CONTACT PERSON/PHONE: = :c 'Z�K�s - �3 s' LOCATION OF SERVICE: — Z a (` �,� � �• The backflow prevention assembly detailed below has been tested and maintained a required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑R�e ed Pressure Principle ❑Reduced Pressure Principle-Detector @�oubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker iSpill-Resistant Pressure Vacuum Breaker Manufacturer ��c�.-�-5 Model Number O �`Id+ot�Q%� Size 3�� Located At P�'�t o �t -�c �:•.-�' Serial Number �~� �s'� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? J e-S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve lst Check 2nd Check Held at �� sid Held at! �psid pened at Opened at Held at Initial Test Closed Tight � Closed Tight � psid psid psid Leaked'7 Leaked``_� Did not open ❑ Did not open '`1 Leaked�rl 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 �1 i c��,e,s�-- ��f-�'"S' SN: o S�l�`p'c, 3 �� Date Tested for Accuracy: f� "'!/— /��o' Remarks: �u-�E`�9 • � The above is certified to be true at the time of testing.� � WeS�.-,� `�S !�!r�` �'°Z`3�'�s' � �/ ` r�,-� ��rr. �� FirmName Firm Address��;��/�"`,,.:'�, f;� 7�f: � � J Certified Tester(print) �"�'� �Q.•w1>�ertified Tester(signature) �;35F- �j n Firm Phone#zl�t"��'t��-/s�z' Cert.TesterNo.�/6c1�� Date !— Z C - ZG 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 f 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 � ' �� MAILING ADDRESS: -t`�c. le_s'=�`f`S 3� ._Z�;/ a� r • �S�/� 3 � 3� CONTACT PERSON/PI�nNF• �;c �-oK e..s - l.��"�' Z , S �s' LOCATION OF SERVICE: ` s - � � a �� %��`� The backflow prevention assembly de ailed 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 ouble Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker g�. Manufacturer ��-'� � Model Number ��4�'j('��-� �''� Size Located At��' o �f��w�-- Serial Number f`��s'7�1�� y- Is the assembly installed in accordance with manufacturer recommendations and/or local codes? /' @-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 at2��sid eld at Z� �sid 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 � � �s- S Test gauge used:Make/Model �l i��u e-t t- SN: O $! 6� 3 � � Date Tested for Accuracy: !�� - ��'"'l r�z' Remarks: �cQ-Ss � The above is certified to be true at the time of testing. �/'e s�.�..� S'-�-s �r�e-�'h�-t-c,�� . .-�-- FirmName Firm Address Z �S�' � v�a/ 1 +"+�'-� ,�v��v�-fl �5�'`5� o v� Certified Tester(print) �� ertified Tester(signature) � Firm Phone# y��' �� '��'Z Cert.Tester No��o�l�l�y Date l ��"Z �'�� * 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 recordkeepin��urposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) �P�-�f� MAILING ADDRESS: S^ �� '� Z o r � - r' y�� 3 � �' CONTACT PERSON/PHONE: ,-� �s - - ` — LOCATION OF SERVICE: �� ' � U �� G�-�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 ❑R�e uced Pressure Principle ❑Reduced Pressure Principle-Detector Ci�oubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker 3 � Manufacturer �''�G�-�-s Model Number � d 7��T Size l� Located At /"i-�- � =7 ��.-r-� ��1� Serial Number � �f �`�f' ,/ Is the assembly installed in accordance with manufacturer recommendations and/or local codes? l'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 /+�psid Held at � �sid Opened at Opened at Held at Initial Test Closed Tighf?� Closed Tight ,_ psid psid psid Leaked�7 Leaked'.I Did not open ❑ Did not open C� LeakedC Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight 1-1 Closed Tight❑ psid psid psid � Test gauge used:Make/Model/�l r�t�-25-1' ��-S'- S�' SN: D �l�'0 3 �`� Date Tested for Accuracy: /� •-!!-/�' Remarks: �c�-�-S� The above is certified to be true at the time of testing. fjtJ�s��.,.� �•f�z.fczs�,,c��-�f�z-�i�su �-3�S Gr✓ C.c/a��;Q�`��Y�� Firm Name Firm A ddress ,�,., ,. � � �� "�.�-� �7c o�!`z� �-" . Certified Tester(print) �y� y ��al,�ertified Tester(signature) Firm Phone# ?��f'�3 �F"��.S'� ?--Cert.Tester No.�(�o�C�1 S � Date �� Z� — Z"� �'� * 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