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2016_1120 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: 9a� �' lSa.f�e��r��/ , �'S�c� 1D0� �c�o�e �� i ��UI 9' CONTACT PERSON/PHONE: Du+/� �-00��'12.r` � �'3� ��[?G ' �Y a LOCATION OF SERVICE: 92 � I�1 ►�'.�fl,�I ��J 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 I�ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer ��f a Model Number g5 C7 Size � �� Located At /Yn,r� �viT�� p�i'�✓e ;;�'�" �7ae'�e�' Serial Number � a gSc� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? o� 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 a� 5 psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight � psid psid psid '�4S 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 Test gauge used: Make/Model t—dxp('aC0 �{V'c�(�C� "' T l� � SN: �C V O�o�c�(�O�O Date Tested for Accuracy: [( (a 3 � �(0 � Remarks: The above is certified to be true at the time of testing. FirmName• � '� (�'a� 1� I�I�tA✓�Pf�Firm Address �Y�� IQ,�,1JQ, ��; ��(�, � 7iC �saf3 � Certified Tester(print)�srd�� (�it�w,pe(� Certified Tester(signature).�-��r�/ �.! Firm Phone# ��l` o��g' �� S Cert.Tester No. V PO o(�0�p�� Date �� 0?0 �7� *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 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) n �p l_/ MAILING ADDRESS: �Ia� � b� � N G� � �l U 1Q� � C��P�ll, � �5U C� CONTACT PERSON/PHONE: �AV� c ni.' r ��-d - g�� {4� LOCATION OF SERVICE: ��I W I��l.�.( � o/ 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 �uble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker f L' �1 Manufacturer ��-fT 5 Model Number �v�� 3 Size �i � �'uw(�' Located At !�'a� eu-�rd �t'I v.f c�,t ✓�"k�� Serial Number �OU�S� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ps 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 °�•l� psid Held at d'� psid Opened at Opened at Held at Initial Test Closed Tight'_� Closed Tight I� psid psid psid ��5 Leakedf' Leaked❑ Did not open �7 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 ��b�'a co 40'��b•"�i�`S SN: C��Z5 o�c�a�CD Date Tested for Accuracy: (� �a 3 I I �p Remarks: The above is certified to be true at the time of testing. FirmName.Do� �ef('� Lb�y l�oc:a�� rs�j�''hFirm Address �y�� 6�1� C��411�,, � �s��3 Certified Tester(print)T/'�r� � ui��e,��'Certified Tester(signature) ��„i��— Firm Phone# r��y- o�� IP�� 5 Cert.TesterNo. vl"De��(�(G�S Date � ao �� * 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) n / /� MAILING ADDRESS: 9 r 1�e. �it� / I�G� �� I6G cs � �� Sal CONTACT PERSON/PHONE: Qav� �oovvf y�a - ��=a -$� a LOCATION OF SERVICE: qa� i.J. .QzfZ.a,� �PGf 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 CReduced Pressure Principle ❑Reduced Pressure Principle-Detectar ❑DoubleCheckValve C-�ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �`�`c<,f��s Model Number � '�� G��i Size � / yt�ifrt�� Located At N� e��'�� O�1�t+��, cLf ✓r11e,�e,-� Serial Number =C � vc��'(S 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 at �•� psid Held at 3' `� psid Opened at Opened at Held at In' ial Test Closed TightL� Closed Tight C� psid psid psid 4.S Leakedf 1 Leakedl=] 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 Test gauge used:Make/Model �cmb racv �� - o�o - `1�(C S� SN: 61 O o?01� (o�, Date Tested for Accuracy: // /�3� i�p Remarks: T�� The above is certified to be true at the time of testing. FirmName=40} �oXf Qa �ac:K7�9� t��s��hv Firm Address 1�l� 1� �Ior IF� C'� �/gl�¢t� ��/ ��Di3 Certified Tester(print)��e� ��i�d¢�'� Certified Tester(signature)��+2�`'� Firm Phone# `I►Y� a ��'(o`-<<5 Cert.Tester No. �� Date � �d 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 / 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: Qa�I ��."�z( K�� , �� (o o ; (o �� 5°r� CONTACT PERSON/PHONE• O�v� UUe.=� � �f 3 a " g6 ¢- g a LOCATION OF SERVICE: 4a f G�.�-1 f�� The backflow prevention assembly detailed below has been tested and maintained as required by commission regutations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ❑Reduced Pressure Principle �Reduced Pressure Principle-Detector f�Pfouble Check Valve ��Double Check-Detector ❑PressureVacuumBreaker �ISpill-Resistant Pressure Vacuum Breaker Manufacturer �a��'S Model Number �5 '� Size � f / V'A��k Located At n/o�'t�i ex��y ��v�2 a� ✓�e��'" Serial Number G J ^ ��y a Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �Z 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 G �' psid Held at c� v psid Opened at Opened at Held at Initial Test Closed Tight❑ Closed Tight ❑ psid psid psid �� Leakedl� Leakedl� Did not open n Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Ciosed Tight❑ psid psid psid Test gauge used:Make/Model Ccsr b r��o �/� " o�o �� SN: U� v �a a�c�o Date Tested for Accuracy: (I � a 3�l t� Remarks: v'��✓� c�.s T rn►..F,r c u p G a�`A -hc,r �i'k �f The above is certified to be true at the time of testing. FirmName .00� ,✓�c� Quy �4��T(�W �t��hq Firm Address �y��" {`/�� Cf , �� / ��i 3 Certified Tester(print)��'oE� ��/7� Certified Tester(signature)rL�� Firm Phone# ��y- o?l�'- (G�C I S Cert.Tester 1�to. dPc�o l (c(p�S 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