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2017_0223 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: � �� 67u v/'�c r» CONTACT PERSON/PHONE: :c �� 'c�� /� - = /7 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 �lReduced Pressure Principle-Detectar ��Double Check Valve �l Double Check-Detector �PressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker Manufacturer �<'`T7� Model Number OC��/'�/ Size� LocatedAt /�. SjU�- (�� 1�� SerialNumber �� 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 ��5s Held at,2�psid Held at�psid Opened at Opened at Held at "Initial Test Closed Tigh� Closed Tight� psid psid psid Leaked� Leaked�� Did not open C� Did not open ❑ Leakedf 1 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 �Z1 s jf�j�5 �C '.5 SN: C�S//a �? U �'j Date Tested for Accuracy: /�.3 0 -/� Remarks: The above is certified to be true at the time of testing. � � Firm Nam C�/vi'I f .- rC j�0 5 Firm Address �� /��'{ �� ,/'/� �'' . Certified Tester(print) �G�'1f? U��"r.''✓ �' Certified Tester(signature)� E� � �� Firm Phone# Y��U S ��"� � �� Cert.Tester No.��O Df3��'/ Date o�-�3 -/� *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 � MAILING ADDRESS: / ` ��S �' 4��'%'u rn CONTACT PERSON/PHONE: /'l-'C �� ' 7� � ' .3�� LOCATION OF SERVICE: � �^�t .I' • 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 G�ouble Check Valve �Double Check-Detector ClPressureVacuumBreaker !�Spill-Resistant Pressure Vacuum Breaker Manufacturer � �c Model Number %[�� Size� Located At S'. r'• �C�Ct�� Serial Number !�� 7 7 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 ��y� Held at,�.�psid Held at�•�psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leakedl=I Leaked❑ Did not open ��i Did not open f I LeakedL I 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 ��%��->�(�� SN: Q�f IDZ� Q� Date Tested for Accuracy: /' .3C� "/� Remarks: The above is certified to be true at the time of testing. Firm Name/`*CT� �'� �`�� "1�� Firm Address �C �� 7�' ' Certified Tester(print)cl d�?�9 �/'�'��G� Certified Tester(signature) � � 's'� � ��`�-- Firm Phone# �d0�Sd�� r�� Cert.Tester No.��QPJj�S/ Date :�?:�3—/� *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 far each assembly tested. A signed and dated original must be submitted to the public water supplier far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: ' � , d�G G�tc vr ct m � CONTACT PERSON/PHONE�y i �t r� G � Z ' 7/�' ��/ LOCATION OF SERVICE: �,7 ��1�11'c'yl t t' 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 flDouble Check Valve �uble Check-Detector ❑PressureVacuumBreaker ISpill-Resistant Pressure Vacuum Breaker Manufacturer �fSL�/ Model Number ��/ Size � Located At S Lt,�. ��u /°f Serial Number QQQ,��a Is the assembly installed in accordance with manufacturer recommendations and/or local codes? S/� `� T 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� G psid Held at�psid Opened at Opened at Held at mt�al Test Closed Tight� Closed Tight � psid psid psid Leaked❑ Leaked 1 Did not open � Did not open i i LeakedG 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 GU� � �`>> ��'� SN: �-5 I�o7j� 0� Date Tested for Accuracy: /� j L? �/7 Remarks: The above is certified to be true at the time of testing. Firm Name�G� /%�� f /' i'� p/D� Firm A ddress �U ��x �� 7 ..� • � ,l . Certified Tester(print) - e��1 il rC/'G✓� Certified Tester(signature) f 0�� ✓ � � ��— Firm Phone#_�(�U'J�� Cert.Tester No��U�� Date o? '�3��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) Ma1LrNG aDDREss: �T/ - ;�"'D.��? Qu c ru vh �- CONTACT PERSON/PHONE: �T'r�.�c� /�'i i .� �� ,�'2 - 7�7 � 3l7 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 1Reduced Pressure Principle �Reduced Pressure Principle-Detector !�H�ouble Check Valve �Double Check-Detector �PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer ¢�'<�'",�.Z� Model Number Yl��- Size.3/� Located At �� c� •1`�'1_CL�� Serial Number n a'��l� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? y� � Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check ,�� 5� Held at�psid Held at�psid Opened at Opened at Held at 'Initial Test Closed Tight�'✓ Closed Tight � psid psid psid Leaked��i Leaked-1 Did not open �� Did not open �� Leaked❑ Repairs/ Materials Used Test After Held at psid Held at psid Opened at Opened at Held at Repair Closed Tight❑ Closed Tight� psid psid psid Test gauge used:Make/Model j��i i7 5�(�"� SN: L�S ��o?��' Date Tested for Accuracy: /��(� 'Y� Remarks: The above is certified to be true at the time of testing. FirmName �L'�/��'1 f /� i2° /"/��`' Firm Address�(�/�� / �� (P )� � � �� ,��a�'�', Certified Tester rint c�d i`J I'z'l�'v�"t' Certified Tester(signature) � "'� � Firm Phone# �('j0-.��6"�Z �� Cert.Tester No�/�oa�S`3s-/ Date a2�;�23"/� * 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: �'/ S O.S�G� C�u ��'u�r+ �� - CONTACT PERSON/PHONE: T!^�C.- � �'� ' / ' T� 3/ LOCATION OF SERVICE: 1 .e,r 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 :7Reduced Pressure Principle-Detector CgBoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker Manufacturer �t�6G� Model Number �0.�� Y Size � t � Located At N,S�� d�� s`�"7 Serial Number /.��?O G� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �G S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check �/t S � Held at�ps d Held at�psid Opened at Opened at Held at 'Initial Test Closed Tigh� Closed Tight fY psid psid psid Leaked�� Leaked❑ Did not open `_J Did not open n Leaked��l Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight G Closed Tight�� psid psid psid Test gauge used:Make/Model ��C'��r1� `�'�-S� SN: l.3v��/o?� a� Date Tested for Accuracy: l�,3C� '/7 Remarks: The above is certified to be true at the time of testing. FirmName�C�� +� �r'!i S Firm Address f/�d /.�J� �� , / �1 / Certified Tester(print�6/1Y1 (T(,�l`"'(i'1 G Certified Tester(signature) � ��ti G�Z� Firm Phone# �p0'�$��oa,n� c�%� Cert.Tester No�/�(J6/S,�� Date ;��3/7 * 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: ' / SG,S� �r�i�'l �• CONTACT PERSON/PHONE:''' � f i� ��l " < ' � 3/ LOCATION OF SERVICE: a/7 �.C.�rGtn qfEr i'• 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 �R�e ced Pressure Principle-Detector ❑DoubleCheckValve ��ouble Check-Detector ;_IPressureVacuumBreaker ` 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �l:t'Sf y/ Model Number [��/ Size �I' Located At S� 1��Gc�� Serial Number �da.5�,rr�l Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �-a 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 3- � psid Held at ��psid Opened at Opened at Held at Initial Test Closed Tightl�� Closed Tight� psid psid psid Leaked'�7 Leaked 1 Did not open � Did not open � Leaked' 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight��:.1 ClosedTight��l psid psid psid Test gauge used:Make/Model /��i��i�/'IS '7'�'✓� SN: G�, /��l� 9 Date Tested for Accuracy: /~:3 D �-/�J Remarks: The above is certified to be true at the time of testing. L� � r FirmName�C7/O� f-'i/'{ f o 5 Firm Address �U�� y ��7 Certified Tester(print)�hn G�`�/�C•+ �i Certified Tester(signature) .�� •�T-�'� .O�i�7 �Y--- Firm Phone# ��1G�`S S D'�Z �7 Cert.Tester No.��00fS3S—/ Date a2 -,�3/7 * 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