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RPZ_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: 3�3 � er ��r � CONTACT PERSON/PHONE: � 21`� ` ►�- ' �b`f° LOCATION OF SERVICE: �- ' e ��- 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 �educed Pressure Principle �Red�iced Pressure Principle-Detector �1DoubleCheck Valve 'Double Check-Detector ! IPressur�VacuuinBreaker 'Spill-Resistant Pressure Vacuum Breaker 1� Manufacturer �(�.�'�S Model Number L�OC�, (YI 3 QT Size 3�� Located At�f1C�5StDf1 �-c��c1r��n� Serial Number ��-3�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? T�`� 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 7t� psid Held at psid Opened at 3.� Opened at Held at I 1 Test Closed Tightl7Q Closed Tight I I psid psid psid �S�j Leakedl I Leaked' I Did not open � I Did not open i Leaked I Repairs/ Materials Used Held at psid Held at psid � Test After Opened at Opened at Held at Repair Closed Tight' I Closed Tight' I psid psid psid Test gauge used: Make/Model�ii�/��ro�C.(� ��"� � SN: �s�p0� Date Tested for Accuracy: 9 �G 1�v � Remarks: The above is certified to be true at the time of testing. Fir�n Name �pQef I -�5,� Firm Address �� 'Y efl �-, (� � � � Certit7edTester(pr�nt) U��1,xti CertifiedTester(signature) Finn Phone# �`C' � 1 fo �� Cert.Tester No.UP��b7�U Date �"d �� *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 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) 1 MAILING ADDRESS: ��03 �ran � �,/' �I � CONTACT PERSON/PHONE: l�x�.i 'raS Z f 4—4g � £30 4� LOCATION OF SERVICE: i ZO Q.1a es Tv,ac� The backflow prevention asseinbly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY �'4Reduced Pressure Principle -Red�iced Pressure Principle-Detector � iDoubleCheckValve ��'��Double Check-Detector ! IPressurcVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker / i 3'� Manufacturer W a�'�S Model Number �F q d�1 Size Located At �f1�'�SS l0(1 M��►"�E"` Serial Number Od�`�0.3 �- d 3� S Is the assembly installed in accordance with manufacturer recommendations and/or local codes? C 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 3`Z' Opened at Held at In' 'al Test Closed Tight� 1� Closed Tight � I psid psid psid a�aJ Leaked l I Leaked! i 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 i ClosedTight I psid psid psid Test gauge used: Make/Model�pMb ro�C� Z�� SN: ��0� Date Tested for Accuracy: �{��ILA Remarks: The above is certified to be true at the time of testing. � 1— �J Firm A ddress l 3 0 3 �+►'Q f'� �(�'', � �� Fn�m Name�p� � � Certitied Tester(pr�nt)�.t!�� _�_Certified Tester(signature) � Firm Phone# ZI�" 7!G—D�7� Cert.Tester No. `�QQ��i/�X1 Date I �1« * 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 IRRIGATION DOMESTIC N FIRELlNE � 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) ,1 � ` MAILING ADDRESS: �.��J (NI?� �✓ j�� `� CONTACT PERSON/PHONE: L�u iS Ci u S !`l- `f`1� 'c�3 0`fb LOCATION OF SERVICE: ��1-O a o �5 �Yac� 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 }�teduced Pressure Principle '1Red�iced Pressure Principle-Detector i IDoubleCheck Valve ' ',Double Check-Detector � IPressur�VacuumBreaker !Spill-Resistant Pressure Vacuum Breaker >� Manufacturer �(�7r� Model Number �-fDO� �� Size �Z- Located At ��/ l��T�e�'► Serial Number 7�7�� 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 AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at 7r Z psid Held at psid Opened at� Opened at Held at Initial Test Closed Tight' i Closed Tight i I psid psid psid Leaked� I Leaked( I Did not open ! Did not open ! Leaked I Repai rs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight ! ClosedTight I psid psid psid Test gauge used: Make/Model l�/►'►��1 CD �� ' �� L SN: z�� Date Tested for Accuracy: 9�/C� ��Co Remarks: The above is certified to be true at the time of testing. /f / ` (/� Firm Name � �`/ �� Firm Address f ��.� W� l'P� �r � Certified Tester(pr�nr) I�Q �� Certified Tester(signature) � � Firm Phone#�-�-/�C � l v Cert.Tester No.� �7-�C� Date � � �� *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