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2017_0404 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 I.D. #0570040 (Customer) Ma1LnvG aDD�ss: 14�,2�/� ,c��-ll� >°�� v�/� �- �7s�3$�/ CONTACT PERSON/PHONE: ��«-�-.�� LOCATION OF SERVICE: �� f'—,�� 2� o �� The backflow prevention assembly detailed below has been tes d and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY I�Reduced Pressure Principle ❑Reduced Pressure Principle-Detector ��ble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker � it Manufacturer ATrS Model Number Q�� Size Located At�e�% � i%Pe L��.`r�C�.��`��ti��Serial Number ��S/`/ o�,�� Is the assembly installed in accardance 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 .2-� psid Held at �' �psid Opened at Opened at Held at Initial Test Closed TightCa/ Closed Tight � psid psid psid �� LeakedC� Leaked❑ Did not open C� 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❑ Closed Tight❑ psid psid psid Test gauge used: Make/Model � �� 4��o ��s� SN: �`?��/�p 5 Date Tested for Accuracy: /l /� i� Remarks: The above is certified to be true at the time of testing. Firm Name �T7�� Firm A ddress /05�7� ��T/�/"��,�A��it� !,[� 7.S13b' Certified Tester(print)�� Certified Tester(signature �` Firm Phone# �2��i1- '�S''a`�a- Cert.Tester No. �t'��S� Date �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 � 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: /�{�Lf I /�- ��(�� '� ��/�?c ��,� � '7�`�S f CONTACT PERSON/PHONE: +�.—��`-� �zc�z�-,'R-�'+2 LOCATION OF SERVICE: �CQ �� '��,��/ � 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 "1Reduced Pressure Principle-Detector ❑Double Check Valve �ouble Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �A"�--5 Model Number 7�� a�� Size � �� Located At1.�..t (�,�/1` �'�.s:�..�c� �i� Serial Number /Q�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 Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �-� psid Held at a•� psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight I�.I� psid psid psid /��S Leaked��7 Leaked�l 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 n psid psid psid Test gauge used:Make/Model�/ld �{��J-�S�L SN: Q7��4�� Date Tested for Accuracy: //�i 7 /� Remarks: The above is certified to be true at the time of testing. FirmName ��'"�� Firm Address_ /�.�75� l�}i7�-�� .Q�li� /,(=7��3,� Certified Tester(print) s�'I�E^/�� Certified Tester(signature Firm Phone# c��/-�jy��/ Cert.TesterNo.��'/�a5�- Date ' �y�`T * 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: /��y� � ��/��S �'.u.� c��A-S �. 7S a-S�/ CONTACT PERSON/PHONE: ✓�o� �cu��L LOCATION OF SERVICE: L^^ �t' � !%-- Co e// %�C. The backflow prevention assembly detailed below has been te ted 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�ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer ��7"TS Model Number �'7 �C 3 £�i Size '!�j Located At -��K l��fc�-�% �'�S: F.��D �r=.�3i�` Serial Number E��/7 3�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e-.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�'S psid Opened at Opened at Held at Initial Test Closed Tightr Closed Tight � psid psid psid �� Leaked� 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❑ Closed Tight❑ psid psid psid Test gauge used: Make/Model��l� 4��"3� ��S ct SN: Q�!��QO S Date Tested for Accuracy: %/�?�le � Remarks: The above is certified to be true at the time of testing. Firm Name�rl�� Firm A ddress /�►5 7� !6�ST� ?�,4+�� .�l� `K 7 5�3�' Certified Tester(print)u%��-�'�e�.SC Certified Tester(signature) Firm Phone# �/�/-35�4��/ Cert.Tester No. ,��/b�S�- Date �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 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) MAILING ADDRESS: /�/�� it� �•�i.�i �R-`�f� �' 7S�3d' CONTACT PERSON/PHONE: � Eza�'�+�-�eie LOCATION OF SERVICE: �a �� o�r �=- " �// Tl'� 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 ❑Spill-Resistant Pressure Vacuum Breaker ��' 4 a Manufacturer ��'��' Model Number �� Size � Located At �E,�' 7� n�e- L��@��i�'�s��.-�� Serial Number � / �'�P �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 lst Check 2nd Check Held at�` � psid Held at ��"psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight �� psid psid psid ��'�S Leaked�� I Leaked�� Did not open ❑ Did not open !7 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 llQ ��'��'/� SN: Q7��a�� Date Tested for Accuracy: �� Remarks: The above is certified to be true at the time of testing. FirmName �T�`�'�7 Firm Address ID575 G�� +�� 5 �- 7533� Certified Tester(print�� S�fz Certified Tester(signature) Firm Phone# e2.��3��- �'�� Cert.Tester No. ,�00/(��S�� Date y/Y// � * 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