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RPZ_2016_1201 IRRIGATION DOMESTIC C 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) ,—_ --��p j � MAILING ADDRESS: � /L C�- CONTACT PERSON/PHONE: � ��7.3 LOCATION OF SERVICE: 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 �Reduced Pressure Principle �Reduced Pressure Principle-Detector �DoubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker '�lSpill-Resistant Pressure Vacuum Breaker I �y � 3 '� Manufacturer W41.�5 Model Number �� —�� Size�_ Located At /�.��"�iy el-��e.}�S 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 7( psid Held at 7i� psid Opened at r�� ( Opened at Held at Initial Test Closed Tight Closed Tight�i psid psid psid Leaked�.1 LeakedC_ Did not open � Did not open �7 LeakedJ 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 !��fl.a�� SN:��f 7 Date Tested for Accuracy: �L'� �� Remarks: The above is certified to be true at the time of testing. FirmName �4 � f� l.l?G�<CCrk��rC�irm Address �Q�� Z- 7 � 7��U..3 Certified Tester(print) �� C-Y�G r� �Certified Tester(signature) Firm Phone#�(7"'T�p �'�U Cert.TesterNo.�C��)�� 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) --� MAILING ADDRESS: ��3(� V� `�L� �� CONTACT PERSON/PHONE: 1 � � " � � ��f 7� LOCATION OF SERVICE: 3� 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 f�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker '-1Spi11-Resistant Pressure Vacuum Breaker Manufacturer ��s Model Number �J�:G/ �%� Size � Z�� Located At � 8 1 Serial Number _��j �� ,b Is the assembly ins lled 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 7� O psid Held at�psid Opened at�_ Opened at Held at Initial Test Closed Tight� Closed Tight� psid psid psid Leaked'�I Leaked� Did not open C� Did not open I� I LeakedC Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight C 1 Closed Tight❑ psid psid psid Test gauge used:Make/Model�i�y1��12'tC'(: /��'��G �/ILS" SN: �� 7 Date Tested for Accuracy: �Z�� Remarks: The above is certified to be true at the time of testing. FirmName� - , C�SFirm Address Y"��i:U�%�C ��0� ✓�{"�►�G1'�IJT�f� 7�0�'� Certified Tester(print) � � �Certified Tester(signature) Firm Phone#��"��'��Cert.Tester No,��01��v�-� Date �Z�j -"/(o * 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 C 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: - (� � - � � �� CONTACT PERSON/PHONE: l.l,l c.�t.r ''� C� 7 �� LOCATION OF SERVICE: C�, - n 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 �educed Pressure Principle ❑Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker i�Spill-Resistant Pressure Vacuum Breaker R 1 / � Manufacturer V"'� C Model Number ��f �1 Size 2, Located At l, � '' r ; � Serial Number �� T I � Is the assembly instal ed 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 r � psid Opened at �� Opened at Held at Initial Test Closed Tight� Closed Tight�> psid psid psid Leaked�7 Leaked�i Did not open � Did not open '.l 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��►'1�(� �.t� /T� k�71 `� l �� SN:��-�{�7 Date Tested for Accuracy: �2�� Remarks: The above is certified to be true at the time of testing. FirmName�Yl .j',��(�c�� Address f((�� aai'C ��71 ra �(o ,�'�� ,r'76�3 Certified Tester(print) y rtified Tester(signature) —�--o � Firm Phone# �)��]��(��—`i�l�L� Cert.Tester No. ��'d Olt��-{3-� Date ��`-'C '� �o * 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