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2017_0404 IRRI6ATION 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) / �5.��o 00 MAILING ADDRESS: .��/ � ��Z� �� l�� CONTACT PERSON/PHONE: �K C��.-rtrk.� 0�l/4/- 5�/ - �/7S LOCATION OF SERVICE: o �-� �T �� '� / �7X- 7� The backflow prevention assembly detailed below has been tes ed 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 �ouble Check Valve J Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �'�✓� ModelNumber �-7�2 7e Size �� k Located At �� e d�.9*�/r"4�lti�ST�+�%n�a�.c°�erial Number /,�S�/ Is the assembly installed in accordance with manufacturer recommendations and/or local codes? eS 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 Tightf5� Closed Tight I_ psid psid psid Leakedn 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 �'J�l�a 4`�'-�Q'�—i� � SN: �"7/C!�t7 Q 5 Date Tested for Accuracy: /l�7�/lf Remarks: The above is certified to be true at the time of testing. Firm Name �`T r��7, Firm A ddress /Q�Z.5 l�s nv-j�j,,t,LC,��S � 75��-3 d' Certified Tester(print) ��£��se� Certified Tester(signatur Firm Phone# ��-3��i-��-1 Cert.Tester No. f�!/IC�'��F'�5� Date � 5� /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) f��y/ � �/�� /� / MAILING ADDRESS: � {,¢ �T� /E� � �� 7S ZSy CONTACT PERSON/PHONE: �^� �u-�`�'� a�u- S��- �/�s LOCATION OF SERVICE: �C� � er )°�u� C'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 ❑Reduced Pressure Principle ClReduced Pressure Principle-Detector �Double Check Valve �ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer 6'�✓'�� Model Number�� Size�_ Located At.�� l�,�u-l� f�'l" `G�cST �'^.�-�-��"�C� Serial Number /�$ `7/7 Is the assembly installed in accardance with manufacturer recommendations and/or local codes? es Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check ��S Held at 3•ypsid Held at -�-� psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight �� psid psid psid Leaked❑ Leaked'l 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�7 Closed Tight❑ psid psid psid Test gauge used: Make/Model �0�1d �!O��s� SN: �7/��QS Date Tested for Accuracy: /��i7�� Remarks: The above is certified to be true at the time of testing. FirmName ��"�-7. Firm Address /0�75 l�S%��,��✓��ll�-S %�' 7S�3g Certified Tester(print)_�%tYX-Y�.�r«� Certified Tester(signature) � Firm Phone# �/��3�i'��-��-/ Cert.Tester No./�/�C�/!• ��2 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) � ''�'��Q�' Ma1Lnv�aDD�ss: �4��/4� � �//� �l�✓�l J�//�-s � 75�s y CONTACT PERSON/PHONE: J�� ?"f/e�'� /�-5��Q/7S� LOCATION OF SERVICE: �02► ��°�-T' ,��Cw[�1 C'o�,a-// �r The backflow prevention assembiy 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 �ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker ��/ � t� Manufacturer G(PR� Model Number �7 /�� e Size T Located At ��T �iK'%��e i�er-`��/�` Serial Number �(�01�(�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? I/�$ 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 g psid Held at�'�` psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight psid psid psid Leaked� Leakedl 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 C Closed Tight❑ psid psid psid / a-a� Test gauge used:Make/Model��`� �d�'J��5« SN: ��oQ� Date Tested for Accuracy: //�i 7�/(p Remarks: The above is certified to be true at the time of testing. FirmName 1TT�� Firm Address /OS7S �,��"k� �,¢2l�,� ,��¢��R� /�''7.5�� Certified Tester(print)��^�'��e� Certified Tester(signature) Firm Phone# �/� ��S' �� Cert.Tester No.��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 LD. #0570040 (Customer) � '"�`�b/°o MAILING ADDRESS: �°�� /� � �'=��5 �- �7.5'�s� CONTACT PERSON/PHONE: ^�1�� C-�c.c�2�'� /�/- 5��' �/7 S LOCATION OF SERVICE: � � f=�£��r �� y��'-// '� 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 ouble Check Valve �Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker �� Manufacturer ��c� Model Number �S Size ��xG��~� Located At�T�.�%��C� �,�e�rr� L�/r Serial Number � ��5� Is the assembly installed in accordance with manufacturer recommendations and/ar 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�-T psid Held at�'S psid Opened at Opened at Held at Initial Test Closed Tightl_ Closed Tight psid psid psid Leaked�� Leaked❑ Did not open � Did not open '1 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 ��`� � �J'l�cS u SN; O 7/��44 S Date Tested for Accuracy: /��7��10 Remarks: The above is certified to be true at the time of testing. FirmName �r• ��- Firm Address ��75 �s3?� �� ,�1�l� !� ?S�3d Certified Tester(print)��°�E^-/ �� Certified Tester(signature �— Firm Phone# �i� 3!�5� a a a� Cert.Tester No. ��b�� 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