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2016_1229 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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. #0570040 (Customer) �� ' MAILING ADDRESS: � ��^ �- CONTACT PERSON/PHONE: e � � LOCATION OF SERVICE: � R The backflow prevention assembly detailed below has been tested and maintained as require by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑Reduced Pressure Principle ❑Re d Pressure Principle-Detector ❑DoubleCheckValve ouble Check-Detector ❑PressureVacuumBreaker riSpill-Resistant Pressure Vacuum Breaker Manufacturer -Q/' Model Number B J��.. �T�T Size � �� Located At �ti� \� �v�'�f� �`� Serial Number l�? �U D �� 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 lnlet Check Valve 1 st Check 2nd Check Held a��3 psid Held ata�"psid ned at Opened at Held at Initial Test Closed Tight'_j✓ Closed Tight I psid psid psid Leaked�� LeakedC 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';J psid psid psid Test gauge used:Make/Model h'1•tJ1�Cu�ti� O� � SN: �U� �/ U� l Date Tested for Accuracy: S �� —� � Remarks: The above is certified to be true at the time of testing. Firm Name II�T°'��re �''`-�— Firm Address �U� �`� ��'�� ''�`"�` �"'t �� Certified Tester(print)`��G�"'��'"� Certified Tester(signature) rn� m Z� G- Firm Phone#o��y �r ` �'�4c� Cert.Tester No. ��ti 1 U 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 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) 'n MAILING ADDRESS: 2UUU �1n1��ti,v��'✓�,� S� 1 LGv y�,C� �I c� ti �Y CONTACT PERSON/PHONE: '" LOCATION OF SERVICE: • Q t'I' ��a� �- 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 C,�Bouble Check Valve �Double Check-Detector ❑PressureVacuumBreaker lSpill-Resistant Pressure Vacuum Breaker Manufacturer �� S Model Number ,J� Size� Located At �a�� Sc.��""� �� S�� Serial Number -1 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�psid Held at�psid ned at Opened at Held at Initial Test Closed Tight�� Closed Tight �� psid psid psid Leakedr i Leaked�'� Did not open '�7 Did not open ❑ LeakedCi 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 ��(,v 2�i" �j�t � SN: �U( � �U�y Date Tested for Accuracy: �—� �'l�o Remarks: The above is certified to be true at the time of testing. FirmName{-�'t��'�a1�2 �'^� - Firm Address �U��°� �'''�t ��i�--- Certified Tester(print)1�1o�c��` �� Certified Tester(signature)� Firm Phone#c�,�y a�J •7 R� � Cert.Tester No.��GV/S�1S U Date ��o��'�v *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) I MAILING ADDRESS: � 2(�� c.�,^r►� V�,� Sv�� lUt.0 � ll�� X CONTACT PERSON/PHONE: �� l�v'�S � �f ' LOCATION OF SERVICE: � � � 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 ed Pressure Principle ��JReduced Pressure Principle-Detector �oubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker CSpill-Resistant Pressure Vacuum Breaker �� Manufacturer � �'v Model Number �� v Size � Located At ��— �� I ��'�. �. 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 ,S psid Held at �• � psid pened at Opened at Held at Initial Test Closed TightC Closed Tight '_. psid psid psid Leaked'�I Leaked� Did not open ��'] Did not open ❑ Leaked�:_l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i 1 Closed Tight'.�I psid psid psid Test gauge used:Make/Model rn•o! �'r�t' ��f S SN: �U� ��U� 1 Date Tested for Accuracy: 5 ' � �' � b Remarks: The above is certified to be true at the time of testing. Firm Name 1�"�'�'1 A'1[.�, F'�� Firm A ddress �U�c�,a G•'�� .tj•�� I G(.�-� � ��Q` Certified Tester(print)�c�a�,.�� V��ur� Certified Tester(signature) ►�I, �� Firm Phone#a �� '7 R � � Cert.Tester No.rJ��S'S'j v 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 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) i� ^ 1`4 MAILING ADDRESS: a�� G� �'n Sv- �J CONTACT PERSON/PHONE: G,�e � � � � 3 LOCATION OF SERVICE: S. (�e 1 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 ❑Re�d ced Pressure Principle �Reduced Pressure Principle-Detector [►�Iouble Check Valve �r IDouble Check-Detector ❑PressureVacuumBreaker '-�Spi11-Resistant Pressure Vacuum Breaker Manufacturer �0�� Model Number�� ►�� Size �-- 1� Located At 1'1 �� 1�'ie �"�' �� '�1 Serial Number � �� `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 �.Upsid Held at�psid ened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked 1 Leaked.�l Did not open ❑ Did not open '�l Leakedi 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 ►n'�•�WQt�' �Lt � SN: �U► 3/�� y Date Tested for Accuracy: S—� Z—� �O Remarks: The above is certified to be true at the time of testing. Firm Name��"�'M0�'1<<'- �''�— Firm A ddress �U�-� �'�'�c (.L.-��`� i�„�1 �� I Certified Tester(print) I��'`al��-�`��"Certified Tester(signature) 1M. rr( i Firm Phone#o� �� t�� '��i�i � Cert.Tester No.��.v�S�v Date �� -�� 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 I, 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) Z.�,�,c) 1�` � MAILING ADDRESS: �� -- k�"' �^�- �"'� � t � CONTACT PERSON/PHONE: rC ��i �''� q LOCATION OF SERVICE: ��- � � 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 uced Pressure Principle ;-!Reduced Pressure Principle-Detector oubleCheckValve �Double Check-Detector �lPressureVacuumBreaker !�Spill-Resistant Pressure Vacuum Breaker Manufacturer �o..� Model Number �v � Y"` � Size � � � Located At �l�- �� '"4- � Serial Number �1�^� �'S S'h� 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 ned at Opened at Held at Initial Test Closed Tight'i Closed Tight '�� psid psid psid Leaked�J Leaked' Did not open =-1 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-1 Closed Tight � psid psid psid Test gauge used: Make/Model �'o'l �� f S SN: �U� ��U 1� Date Tested for Accuracy: S-� L� � Remarks: The above is certified to be true at the time of testing. FirmName ��'�wL�e- ��"�- Firm Address �U��'� �� W'`�� `la� �X Certified Tester(print) n��` �c.�n u✓" Certified Tester(signature) �'1. l�(�'-- Firm Phone#o� <<f �1� I -10.4( Cert.Tester No.]�1(�r•�/�'�O Date � �-`a�-� 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