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2017_0217 � ��r 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: °3o S' /,,c�.v�,� � ��t' Co �� S�► 9 CONTACT PERSON/PHONE: e e/ V�ir►cc,r� �o�'� - - �''�S LOCATION OF SERVICE: 301 � �a-�-'�� T � oI 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 C7Double Check Valve V'bouble Check-Detector ❑PressureVacuumBreaker ��lSpill-Resistant Pressure Vacuum Breaker u Manufacturer �]��(�Y\ S Model Number � 50 �S� ,��Size � Located At � C/�r �ti►�,d l Y1 Serial Number 6 0�(L`(� Is the assembly installed in accardance with manufact er recommendations and/or local codes? C. Reduced Pressure Princi ]e Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at�psid Held at �'l�1 psid Opened at Opened at Held at Initial Test Closed TightC�'" Closed Tight � psid psid psid 1'�SS Leaked❑ 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 Test gauge used: Make/Mode1C-Qrt br��o �o " avo_ �� SN. Q f o aa a�O � Date Tested for Accuracy: I//�3�/� Remarks: The above is certified to be true at the time of testing. Firm Name .�b� /!'��U v/�c��/��ffi�Firm Address � y�� d1��..sz. C� Certified Tester(print}tfrQP��e�� Certified Tester(signatwe)��-�-'"" � Firm Phone# ��y o?/Q' � �//S Cert.TesterNo. �l o��o��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 I.D. #0570040 (Customer) .� ,� -�y S f MAILING ADDRESS: 361 S � I�eM.'{c+� � GI� C a �� //� � 0 � CONTACT PERSON/PHONE: Q c i Y'k� ga- -O 7'S} LOCATION OF SERVICE: 3o I 5� �t+�. � �-G' � 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 ❑Double Check-Detector ❑PressureVacuumBreaker [�Spill-Resistant Pressure Vacuum Breaker Manufacturer �JJ 1 � k�n�j Model Number -1 J��,�L Size�� Located At �4�� (�,Gar C1` b J i��t�1`� Serial Number �-i 2 6 20 3�, 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��psid Opened at Opened at Held at Initiai Test Closed TightCt� Closed Tight � psid psid psid P��S Leaked❑ LeakedC� 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 ClosedTight�J Closed Tight n psid psid psid Test gauge used:Make/Model �dk�ru�o `�O' a�U- �'� SN: 0�0�o�o��p�o Date Tested for Accuracy: //�a 3�� Remarks: The above is certified to be true at the time of testing. Firm Name�b� n/�iC� �ay ��„ /�s�Firm Address_�yl� ��,�a� C-f{ /�//�,. , �i' �sv/ 3 Certified Tester(print)15�UQ� L�,l��f Certified Tester(signature��j j—� Firm Phone# �/y-��g` � �/( S Cert.TesterNo. ��a��'� S Date a 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 Y 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: -�� S• �� l� �'d ��o��- �� ' �SO�� CONTACT PERSON/PHONE: Q � �inc /� g,�-a� y G�'S� LOCATION OF SERVICE: 30 1 S . De�U� � �</ 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 C3'�ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker s� Manufacturer�'f S Model Number L�Oo m� Size ( Located At �e��'Cr h,�G1n�v�G� �3 U 1�d(v�S Serial Number ��,�,2 Is the assembly installed in accardance with manufactu r recommendations and/or local codes? Q^ 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 Z•� psid Opened at Opened at Held at Initial Test Closed Tightu'� Closed Tight � psid psid psid G�.S'S Leakedf 1 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 Cl Closed Tight❑ psid psid psid Test gauge used: Make/Model C�Q�D%a�v `70" o?o� � �l�s SN: ��v o?aa ro �O Date Tested for Accuracy: �( �o�3 �/ � Remarks: The above is certified to be true at the time of testing. � Firm Name A0��a'iC'{�a� gR��(��-f ji.� Firm Address 1y/� �/,6�`�er� C'� � �/�eti, ,� �f�'I ; � Certified Tester(print)�5r�,e� �,�� Certified Tester(signature)�!��--`� Firm Phone# ��y-o?I�" � �f �S Cert.Tester No. ��°U��n�� 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: ��1, S� ��t��v� i ap � Z , Cc�� 1 S o (°� CONTACT PERSON/PHONE: �t,l� � t y��,c h� / b$Z- 2Zy—O'l 5'l LOCATION OF SERVICE: 7,c� l S- �v�ko n �'a�o i2� 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 B'bouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker ►1 Manufacturer t�� 1 k�r s Model Number �5 C7 Size� Located At �1 t'�"G✓ �0{.�^�hc� �Ov 11��►V�� Serial Number �c� � �, 1� Z Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � L 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 i"3 psid Held at 2•7 psid Opened at Opened at Held at Initial Test Closed TightL� Closed Tight P� psid psid psid p(�S� Leaked_� Leakedf I 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 1-1 Closed Tight�� psid psid psid Test gauge used:Make/Model�o h bya c o ti o z o�=C'k 5 sN: 010 2 Z Z 6 6 Date Tested for Accuracy: l��23 � �6 Remarks: The above is certified to be true at the time of testing. �n FirmName,DU1 �IGX� 12ti�� i'�i-m Address 1��11 �b��c,►�C Ck • Certified Tester(print) I5Y'0►e� �G�ilhb�'',� Certified Tester(signature) Firm Phone# 21`�l" Z�' b`1� S Cert.Tester No.__ g 1� d c� i b 6 7S Date 2 I 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