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2017-0228 � IRRIG�TION 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) , Q„j�JC. ��Ur - „�, `� '��f.�l MAILING ADDRESS: � CONTACT PERSON/PHONE: � ��IS ' 'S� � � LOCATION OF SERVICE: � �s �NL� 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-Detectar �oubleCheckValve f 1Double Check-Detectar !�1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker � ic Manufacturer � Model Number �'�� Q� Size Located At /V,E:�T(> i�(; �� Serial Number �J�� Is the assembly installed in accordance with anufacturer 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 at0�•� p ' Held at�psi Opened at Opened at Held at Initial Test Closed Tight'�__� Closed Tight � psid psid psid Leaked❑ LeakedC Did not open � Did not open '' I LeakedCl Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight n Closed Tight I� psid psid psid Test gauge used:Make/Model Vvrf t��I�S��".✓ SN: (��C�� Date Tested for Accuracy: � � j� Remarks: The above is certified to be true at the time of testing. FirmName_��-�f �"�1'�-�' Firm Address ��M ��" �l� Certified Tester(print)�I� . c Certified Tester(signature� Firm Phone# ��z��t7��c"�O`t�� Cert.Tester No. �� 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: ��%I �- �/ � # �'��' �� CONTACT PERSON/PHONE: S � '' S LOCATION OF SERVICE: C� �' ;� � Tbe 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 �R�uced Pressure Principle ��Reduced Pressure Principle-Detector C�YDoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker riSpill-Resistant Pressure Vacuum Breaker Manufacturer V�1�f'TS Model Number �� f� q T Size Located At �J`�-�'�� C:�� F-�1 Serial Number g��`�t� 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��ps Held at �°�psid pened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked''�. I 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 Vue1 �d`lU�� SN: �=�� Date Tested for Accuracy: l � Remarks: The above is certified to be true at the time of testing. FirmName_.-1-Q�A-� l�� Firm Address h��(-r� �G�l�!"� ��11� �- Certified Tester(print) ��'��/�� Certified Tester(signature) � � � Firm Phone# �` ` �� ,�� Cert.Tester No. ��'�, Date � aD � * 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 s IRRIGATION DOMESTIC FIRELINE ✓ The following form must be completed for each assembly tested. A signed and dated ariginal 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) , �-r� MAILING ADDRESS: �� 'i `� ►�C'-r�l , In. 7�� CONTACT PERSON/PHONE: �/� � i � ', 6 LOCATION OF SERVICE: ( S � � � �` 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 ❑Re uced Pressure Principle-Detector ❑DoubleCheckValve ouble Check-Detector '�lPressureVacuumBreaker �]Spill-Resistant Pressure Vacuum Breaker Manufacturer Vl,4ia{� Model Number �� .� '�� Size �� Located At ��c�1�(7 C.�' �ukl ��1� `lA,t�l��' Serial Number � ,� Z Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker G�� 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 Tight� Closed Tight I� psid psid psid Leaked❑ Leakedi� Did not open ❑ Did not open n 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�l S�i�.� SN: �� Date Tested for Accuracy: � � � � Remarks: The above is certified to be true at the time of testing. FirmName �.�C�� Firm Address � � �J � "i� �� _� -, Certified Tester(print) c.�� (.�Certified Tester(signature �� Firm Phone# � �" pC�0 ' ` �� Cert.Tester No. a��0�� 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 , IRRIG�CTION 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: . > � r � ,� � ?5�! CONTACT PERSON/PHONE: _ iM� �Z- '. LOCATION OF SERVICE: � ,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 ❑R�,�uced Pressure Principle CReduced Pressure Principle-Detector I�ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �� Model Number� �� Size �� Located At ��'V i(.�9��f � �f�� 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 �.r�� 1 st Check 2nd Check Held at�psid Held at ��psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight � psid psid psid Leaked��l 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 Closed Tight❑ Closed Tight� psid psid psid y � ,n� ` �f Test gauge used:Make/Model �t �'ll+l1�S � � SN: E-!�� 1� � Date Tested for Accuracy: � 1 �� Remarks: The above is certified to be true at the time of testing. Firm Name��( , `� Firm Address �� ,�-� Certified Tester(print)� � �� Certified Tester(signature� � (� �7 r� F �� Firm Phone# �/� G "'e��'�� Cert.Tester No.��.b`�� 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