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2017_0120 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: �� /L��O r� �k�y , CoOr�� . � �� I `� CONTACT PERSON/PHONE: Oc�vQ 1�-�,�,�r /Q �� -�Ga�t - :3r�4`9 LOCATION OF SERVICE: �c{� F(�2��e;f 1P(Cw�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 ❑Reduced Pressure Principle ❑Reduced Pressure Principle-Detector ❑Double Check Valve C�uble Check-Detector ❑PressureVacuumBreaker '��Spill-Resistant Pressure Vacuum Breaker Manufacturer ��v a.��' S Model Number �� '� Size � Located At �c�r.` � 5 0�11,Q.c�S f- �t D�-t v� Serial Number (�..K�C �0 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e 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 3�� psid Held at�•� psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight psid psid psid 4 t Leaked❑ LeakedC�' 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❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model CCU�,br�c� �d- �o- 7�(C S SN: C,i O o?�o�� Date Tested for Accuracy: �� 013 � I(v Remarks: The above is certified to be true at the time of testing. / /� �� 1 / Firm Name.oo� dUc��cev �u��'�"�aW Firm A ddress �y�I� /t'�/`�e, �,t��le�, �j}� �S°/3 � � Certified Tester(print)��I'U� l C�rw�(� Certified Tester(signature)s��--T � Firm Phone# v?��{- �[g -G�(( s Cert.Tester No. ��Q��5 Date � 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 FIRELINE L/ 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) � ;y� MAILING ADDRESS: �� f�� o f 1�'�-� Cv �� 0 � � CONTACT PERSON/PHONE: c�v�e. oca�^�fi' �1 -� . _ � a q` LOCATION OF SERVICE: �R3 Fr�e�r (�-F Pl�w� 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 �ubleCheckValve i IDouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �'�1 �.'�"'Ef Model Number �F b cs � � 3 Size ��`t �� Located At �/'K�� So�.�'l.eq s� v'� a�r�v.�,� Serial Number ��- O a a O( � Is the assembly installed in accardance with manufacturer recommendations and/or local codes? �5 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 �- � psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight � psid psid psid '�4�5 Leaked❑ Leaked❑ id 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 �("sy�b/'ct c o �6-�'� ' � S SN: �+�o?a a(o�'o Date Tested for Accuracy: _ ��/(,, Remarks: The above is certified to be true at the time of testing. f �.� � TS�,� %�� d�l� ��,,d-ll� ,,7�' �s�� FirmName-c7o� � .P'+(-F D �( �oW Firm ddress Certified Tester(print}ZS�'cr�t/ C.�be�� Certified Tester(signature)��-'� �.�-��--� Firm Phone# 01��' a 1 $" �y�S Cert.Tester No. ��i�CO��7�S Date � �' 1� * 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) MaiLrrrG a��ss: �� 1=��=�f j�(c�.�.,, Cap,��-.��; �' ��s°� � CONTACT PERSON/PHONE: t� v � � - '" ��2- '�. - 3 q LOCATION OF SERVICE: S��( 3 {=if"ee.po r-f" l�wv 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 C�Double Check-Detector ❑PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker Manufacturer F�GO Model Number �S S� Size a �� Located At 5�� a s f o'f' c(�iv'� c�.f �� Serial Number �{ a g�6 a Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �-5 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 Opened at Held at Initial Test Closed TightC�' Closed Tight I� psid psid psid �4 sf Leaked:rl Leaked':1 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�y� b�'�c o `�G -�s%a - �C 5 SN: C>(L:� oZ o'�C�,� Date Tested for Accuracy: �t I a 3I � �v Remarks: The above is certified to be true at the time of testing. � � �ac %�s�ii.� jt�� (� � � /( 7�-Se � Firm Name •�c� e�e �y ��7io!Firm Address � P-�•(. �f l � ��i ' � .� Certified Tester(print)r!'�;;� � �tiNx.�('� Certified Tester(signature) ��.�-- Firm Phone# o��4 - oZ��- Cv`�l<<j Cert.Tester No. ��'�'�5 Date � � f�" *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 V 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) � D MAILING ADDRESS: �� re2. o�'� r ��` CG � �fdj y CONTACT PERSON/PHONE: I a Ve �c�+�Q..T `� a-8��1 � 3� �l �- LOCATION OF SERVICE: �'`tq � -a,rt ►`'(cwy 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 uble Check Valve ��Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �e�c c Model Number 8�S y Size o� � Located At �� c"� dl�`U sL �.t �e.'{'�.,f" Serial Number �O� � �'`(�l 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 a�� psid Held at �•� psid Opened at Opened at Held at Initial Test Closed Tight'�Y Closed Tight C� psid psid psid Pu f 5 Leakedl l 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❑ Closed Tight C! psid psid psid Test gauge used:Make/Model Ccs�6r�c� �{0� v�LG- l�'S SN: OL��ao?(��, Date Tested far Accuracy: t 1 � a 3 1� (P Remarks: The above is certified to be true at the time of testing. Firm Name,Lb� ��e�(f P��,- ��a� �Firm Address � � �(��- r�� (�_ ��f � t��1��., '7"?S �� Certified Tester(print}.�/`a�.� �'rmba��'� Certified Tester(signature) ��---��—�� Firm Phone# ��l ' ��g' �i-�l� S Cert.Tester Na �{`��r��°�c�� Date 1 � � * 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: �� t'' o`-f �k`"'`� �� 0� y CONTACT PERSON/PHONE: o� lEoa��+�� 2 � - �Y`�a LOCATION OF SERVICE: �`I q �ra.�DQ�-F Pk w•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 ❑Reduced Pressure Principle CiReduced Pressure Principle-Detector [�H'ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer ��`��T"S Model Number d�=��^3 Size j��1 �' Located At �� '� pr�ve ,� �'�� (+ Serial Number a v v 3�ol Is the assembly installed in accardance 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 a�� psid Held at o�-� psid Opened at Opened at Held at Initial Test Gosed Tight��''� Closed Tight C� psid psid psid �k Sf LeakedL; Leaked❑ Did not open ❑ Did not open �� I Leaked❑ Repairs/ Materials Used Held at psid Held at psid � Test After Opened at Opened at Held at Repair Closed Tight u Closed Tight�! psid psid psid Test gauge used:Make/Model �Cr�,b!`a to 7b -oZO�- 7�C S SN: a 10�a o'2�(o Date Tested for Accuracy: �d 3 �I (o Remarks: The above is certified to be true at the time of testing. � n ;�,-�� IY�3 f�� / f � 7�` �5��3 FirmName.(�O� ��( Qay �Cf�C��w Firm Address i G-hrZ C � !�� e� , Certified Tester(print)T�'�e � �-tvrK1 b,��" Certified Tester(signature)_.�--�� Firm Phone# ��"'�1 g"� �(l S Cert.Tester No. �1 C30��(�3"s Date � ab �� * 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: �"�� ,��+� �`�i�t,�y � �o��Le �� }soI� CONTACT PERSON/PHONE: P��e �f��` � 4�rr2 -S'6 R - 3�1�(•� LOCATION OF SERVICE: �4�( �+-��po r f- ►�k ur�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 ❑Reduced Pressure Principle �7Reduced Pressure Principle-Detector ❑Double Check Valve �ouble Check-Detector ❑PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker �""�� i� Manufacturer �"�d'��s Model Number � s� Size � Located At �� Q��re, �� va�..«' Serial Number ��' �N�`� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e 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 a�� psid Held at a•�j psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight �� psid psid psid Pii� Leaked❑ Leaked��-1 Did not open C 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 Ccnb��co �to - 300- 7�,Cs SN. prG,,?aa�� Date Tested for Accuracy: [(TI 1(0 Remarks: The above is certified to be true at the time of testing. FirmName.DO� /�p.X� pav �rG/�l6wTs�i,.� Firm Address ��1�� /�lr'lC�i.0 C� ,��1�,� �/ �SOI� , , Certified Tester(print)SFae � ��(�� Certified Tester(signature)�a°'✓� �---�� Firm Phone# ��y' a��- (r�N(5 Cert.Tester No. ��OGI(c�,�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 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: �� 'fi,�po r-f il kwy , Ce�� `/�' � SOl�j CONTACT PERSON/PHONE: vav.� ��G�u � �(�a — 8Co q - 39�1 a LOCATION OFSERVICE: �� r-�.sz. P�ft- {��CwY 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�Hrouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �a-}-} S Model Number ��'? "'� � Size 3 4 Located At V��, ��" �"� Ca�'�ur G� ��m-. Serial Number a�3(o� / Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e> 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 Opened at Held at Initial Test Closed TightC� Closed Tight C`Y psid psid psid Pq S Leaked�� Leaked� Did not open I 1 Did not open i 1 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 �611�r�zcb �0-o?oci ' 7�S SN: G��0.��a G>(o Date Tested for Accuracy: l l�a 3 �l(o Remarks: The above is certified to be true at the time of testing. FirmName.c.�c� ,�� V ls'ac��mr TPsfi�;,g Firm Address l�//3 f��Lt-,�Q L� � 1��1&1, ��}' �S0� i Certified Tester(print�sl'Qe � �.Ctr�b�'�� Certified Tester(signature) �� Firm Phone# o��Y� a�S- f�K! S Cert.Tester No. +��DD �(o�p�S Date � o�Q / *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: �� +� �� 'kw Co -�.l/ �' �s�� 9 CONTACT PERSON/PHONE: �v > oo:•�� - 8 Cv`� -3�l Y•z LOCATION OF SERVICE: 3�� e �rt ��•�:� 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 ❑Double Check Valve �uble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker �� Manufacturer ti��`�t Model Number �� Size Located At �u��f �F �ar�r afi _��hc,�c�,, Serial Number C)G '-( I Is the assembly installed in accordance with manufacturer recommendations and/or local codes? L 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•O psid Opened at Opened at Held at Initial Test Closed TightC� Closed Tight ��+� psid psid psid �c�[�5 Leaked❑ Leaked❑ Did not open ❑ Did not open C 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 �Uvt�('c2c.� �6" o�c��'�k� SN: �i L�a oZ C�� Date Tested for Accuracy: ��T) t (,o Remarks: The above is certified to be true at the time of testing. FirmName<t�c�� „�p�(� ��v Q�c(��ow �c��Firm Address ��1�� 6i�e� Cf� A��P�, � /� �"SGl 3 / i � Certified Tester(print)�s✓'�+e� LC�y►�be�� Certified Tester(signature) � Firm Phone# a��- �� g - �%�/l S Cert.Tester No. �"�O6j�%l�� s Date 1 vZ0 �� * 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) ( -�y MAILING ADDRESS: �� a �'# I,�'°'�-� o y� I �' � Sa�� CONTACT PERSON/PHONE: �sZ �{oo�. �- 3 - 6� - 3 k�a LOCATION OF SERVICE: �� tr�e P�rf (�k wv 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 Manufacturer �'v`a-�� Model Number �� 1 Size �r Located At Vu��f r� �i� rJ� C�r�,,�r Serial Number I g�G� � Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e 5 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'd psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight i psid psid psid �aSS Leaked❑ Leaked[� Did not open f- 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 �G��'ctc� �(0 '�DU- �K� SN: �� o��o��o;(o Date Tested for Accuracy: �� 3 f! (o Remarks: The above is certified to be true at the time of testing. Firm Name•D�� p�-� �y ��d�,l �e�l t� Firm A ddress �y« ��. C� ��,�/ �S��3 ._- __r-- Certified Tester(print)1s('�t�I �b��" Certified Tester(signatwe}.� Firm Phone# o�� I- � ��' (r7�l S Cert.Tester No. ��°��b��S Date � a�• ��' * 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: ��' ��e-�, f f P�w� C6 �� / � �� CONTACT PERSON/PHONE: av e I-{auvei� I Q�a2- �o�( - ;��{r{d LOCATION OF SERVICE: �� epo�{' �wy 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 �iReduced Pressure Principle-Detector �ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker :�Spill-Resistant Pressure Vacuum Breaker Manufacturer ��-+�5 Model Number �'��''^` Size �� Located At �� c Fa�'�- ��fi n1c;'��e..�^ Serial Number C�1�d 3'S$ 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 �� c^. psid Opened at Opened at Held at Ini�al Test Closed TightL�Y Closed Tight Y psid psid psid tiS 5 Leaked�� Leaked� Did not open C 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:�l psid psid psid Test gauge used:Make/Model �b�Yca �b '"o�Uo•- �S SN: U lO��a �a � Date Tested for Accuracy: � � I o2 3 'i lo Remarks: The above is certified to be true at the time of testing. FirmName.Do� �� y �u��i1�Ns'f�r�Firm Address �N�� b��Pc.,,e C.� �/�/�py� ��` �s�13 � �_ Certified Tester(print) �s�a F� ��1m�e�� Certified Tester(signature� � Firm Phone# a�4 -a 1 g- �i��I S Cert.Tester No. ��Y 6��t'3 S Date / o�e� / �- * 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