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2017_0228 t -IRftIbATION 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) ,�iy, MAILING ADDRESS: �� G� �';'� 5 � /�' �'�"`'"� CONTACT PERSON/PHONE: �� LOCATION OF SERVICE: ' C� 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�e ced Pressure Principle ❑Reduced Pressure Principle-Detector E�'DoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer Model Number � [�� Size `��/, Located At V�{,'7 �• �� /��i15�r��Serial Number ��j�� 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 �'�psi Held at�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight ❑ psid psid psid 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 � ,��s t.� �� Test gauge used:Make/Model `f� !61�,� `�6�J SN: Date Tested for Accuracy: ` � � Remarks: The above is certified to be true at the time of testing. �� t� FirmName 11L�� Firm Address �� !.c' � �� x � ,,--r.y Certified Tester(print��c.�7"�� Certified Tester(signature� a Firm Phone# �G � � �� Cert.Tester No. � �f Date `�� / 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 IRRI�ATION 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: �C s (� A! S �t�`J ` �. ��'�1� CONTACT PERSON/PHONE: �/ � ' � LOCATION OF SERVICE: 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 C9'�ouble Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker �� lQ�� Size � �, Manufacturer Model Number Located At Y�/"'t'c�� IN•l,�J�� L-�JJ6'c:i� Serial Number �7'��Va Is the assembly installed in accordance with manufacturer recommendations andlor 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�psi Held at � �id Opened at Opened at Held at Initial Test Closed Tight� Closed Tight psid psid psid Leaked❑ 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 ClosedTight❑ ClosedTight❑ psid psid psid �j /,�� Test gauge used:Make/Model 1 01�� I �`J SN: C:�� Date Tested for Accuracy: � � Remarks: The above is certified to be true at the time of testing. FirmName ��`� f� Firm Address�� fi �T ,I/�� Certified Tester(print `�� Certified Tester(signature)`� `' i"�_ Firm Phone# �� ',;�'i7�7C'��.� Cert.Tester No.l/� ��( 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) n�'� J MAILING ADDRESS: �' � � " �� S �� h�, ��` Ix �t��/ CONTACT PERSON/PHONE: /� S 7�` U' ,� LOCATION OF SERVICE: Q� � 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 �lReduced Pressure Principle-Detector ❑DoubleCheckValve '-1Double Check-Detector -1PressureVacuumBreaker -lSpi11-Resistant Pressure Vacuum Breaker Manufacturer �/�g� Model Number �P�/��Q� Size � �� Located At �UU�#1"] OT�� 1�e•� V�.%�erial Number ��Y` Is the assembly installed in accordance with manufacturer recommendations and/or local codes? � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker n�� Double Check Valve Assembly Relief Valve Air Inlet Check Valve ��J 1 st Check 2nd Check Held at �' � psid Held at�7'S�a psid Opened at Opened at Held at Initial Test Closed Tight��s Closed Tight � psid psid psid Leaked'�i Leaked',�'� Did not open � Did not open '�l 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 , P' h Test gauge used:Make/Model I S � SN: (��D�� Date Tested for Accuracy: � `� Remarks: The above is certified to be true at the time of testing. FirmName_•'�I �� Firm Address�P �� T�� . Certified Tester(print)� t�r'�� Certified Tester(signature)�� Firm Phone# ��°�'�'��3 Cert.Tester No.��Q('�Z,�J Date `� ag _ *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