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2016_1220 �- 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: I3D� W e✓ ��r � 1 � CONTACT PERSON/PHONE:�ou r5 I 4 2/5� '`f t� "� 0`fd LOCATION OF SERVICE: �'Zl�A a e5 �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 '-]Red�iced Pressure Principle-Detector b¢DoubleCheckValve !Double Check-Detector i I Pressur�Vacuum Breaker i Spill-Resistant Pressure Vacuum Breaker l_ � � ��r Manufacturer � �Q 'T S Model Number �7- � � 1 Size Located At S C1� �1`�DP��1 � C� Serial Number /� ��o�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? CS � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at��psid Held at��psid Opened at �pened at Held at I�ial Test Closed Tight!� Closed Tight�l psid psid psid �j� Leakedl I Leakedl I Did not open � Did not open ! Leaked I Repai rs/ Materials Used Held at psid Held at psid I Test After Ope»ed at Opened at Held at Repair ClosedTight' i ClosedTight I psid psid psid Test au e used: Make/Model �'Z� �� SN: 2��' I � g � Date Tested for Accuracy: I Remarks: � The above is certified to be true at the time of testin . I g /l � � r� , l 1 � e/ I FirmName �6l —� � Firm Address � � �lJ� l °U� �I� `l I 1 � � Certit7ed Tester(pi-�nt) (�l� 1 Certified Tester(signature) ! Firm Phone# �`t ' �7"v Cert.Tester No. ��(�� Date 1 �� l � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy I IRRIGATION�_ DOMESTtC 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: l'�03 w�'a►'�5 ey r� CONTACT PERSON/PHONE: i c,�a '2� - `t !� � d�f"� LOCATION OF SERVICE: I ZD Q r'-S-�vy�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 paraineters. TYPE OF ASSEMBLY iReduced Pressure Principle :iReduced Pressure Principle-Detector ��CDoubleCheck Valve 'Double Cl�ecl<-Detector f IPressurcVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker �1 Manufacturer � �S Model Number (�� Size � GJ ,�` ,/ Located At se Q� �v � � ��' Serial Number J��Y 7�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �eS Reduced Pressure Princi le Assembl Pressure Vacuum Breakec � Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at Z�0 psid Held at�psid Opened at Opeued at Held at Injjial Test Closed Tight'� Closed Tight�l psid psid �sid �as5 Leakedl I Leaked� i Did not open i Did not open ' Leaked ', Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTightl ! ClosedTight I psid psid psid Test gauge used: Make/Model �m bra co �D- �0�TK SN; Z�SOO(� Date Tested for Accuracy: � �� Remarks: The above is certified to be true at the time of testing. i Firm Name�� I '-�� Firm Address V�-�� LPY �r' � \ � � . Certitied Tester(pr;nt)�t Certified Tester(signature) I �[— � - � �� Dat � v� !� Finn Phone# � �� `fU Cert.Tester No.,U/ � / 7 I * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT PARTS I 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: I 3a� (�.}�i►� CY �►'� � CONTACT PERSON/PHONE: �6u�s ciu Z�`f' � d� LOCATION OF SERVICE: J ZD � a e5 �✓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 iReduced Pressure Principle '.-'Red�iced Pressure Principle-Detector �Double Check Valve IDouble Check-Detector '1Pressurc;VacuumBreaker -',Spill-Resistant Pressure Vacuum Breaker Manufacturer UV�1t't� Model Number�d 7 � � � Size z `` Located At G�m�-T frL'I� �"`'s� C'` Serial Number �7�D 0 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � Reduced Presstire Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at 2�� psid Held at Z a3 psid Opened at Opened at Held at I ial Test Closed Tight?� Closed Tight j� psid psid psid �a55 Leaked l I � Leaked; i Did not open I Did not open ! Leaked � Repairs/ Materials Used Held at psid Held at psid I Test After Opened at Opened at Held at Repair ClosedTight' I ClosedTight I psid psid psid � Test gauge used: Make/Model��^b�-�-� �r Z�� SN: .�-�J D�� i Date Tested for Accuracy: 9 � �� Remarks: The above is certified to be true at the time of testing. I Firm Name �Q�Q�� I -s- S� Firm Address �3�� l� �r� �� I �� f�� 4I ^ � Certitied Tester(pr�nt) �� IJO�f l Certified Tester(signature) � � - �� OlY�b7 � xo l� F irm Phone#2 ! �p Cert.Tester No./J � Date � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT 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) i MAILING ADDRESS: f 363 l��aV�, le►- � �� CONTACT PERSON/PHONE: u 1' Y �`� ' �'� �`� LOCATION OF SERVICE: I ZO �tJa C �5 � r�CC- The backflow prevention assembly detailed below has been tested and inaintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ` iReduced Pressure Principle '-?Red�iced Pressure Principle-Detector �ouble Check Valve 'Double Check-Detector ! IPressurcVacuumBreaker ?Spill-Resistant Pressure Vacuum Breaker , f� Z� / Manufacturer �QTTS Model Number DD'7 /Y)-/ � Size Located At ��►�� i�� e�r C�< Serial Number �J` ��23 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �S _ � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Doub(e Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �� 7 psid Held at Z�a psid Opened at Opened at Held at 1 ' ial Test Closed Tighti Ip Closed Tight �7P psid psid psid QC,�j Leakedl I Leaked' I Did not open � Did not open ' I Leaked I Repai rs/ I Materials Used � Held at psid Held at psid I Test After Opened at Opened at Held at Repair Closed Tight i I Closed Tight' I psid psid psid � - zoD-�k Test gauge used: Make/Model�brt�Cc� � SN: ZS�}� � Date TestedforAccuracy: ��o �/� j Remarks: I The above is certified to be true at the time of testing. Fir�nNamel,��' ..r� JD Firm Address � 3L3 �� Cd ��►� I —T, 9 � � Certified Tester(print) ��O i� �I��Certified Tester(signature) � Firm Phone# ��T— �o-g�� Cert.Tester No�/ 0D0�7� Date � �d �� I * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT PARTS I 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: �3�� ed �r �O e,( t � CONTACT PERSON/PHONE: �-ouiS c.� 2/`� ' `� �' �`f"� LOCATION OF SERVICE: I 7A C CS ��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 IReduced Pressure Principle -1Reduced Pressure Principle-Detector �DoubleCheckValve !Double Check-Detector i IPressurcVacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker , l � ir Manufacturer�,( ��`t� Model Number (�Q� �� Q � Size�_ Located At I��i/(Q �/1�`.�'S%f�i'1 Serial Number O�S7 �� 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 at��psid Held at /� � psid Opened at Opened at Held at I ial Test Closed Tight� Closed Tight)C1 psid psid psid �Qjs Leakedl I Leaked' � Did not open I Did not open : Leaked ', Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight' i ClosedTight I psid psid psid Test gauge used: Make/Model �ivr �-O ��z� ��- SN: ��8�� Date Tested for Accuracy: � � �o Remarks: The above is certified to be true at the time of testing. e�l �� Firm Address �� ` � ' Finn Name � `'`-'�� r ��r �� i�f ` ` � Certitied Tester(pr�nt) Q U�G( Certified Tester(signature) �j � �[ Firm Phone#� I ` �� —��7� Cert.Tester No. S _Date �� 20 � ` * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy i