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2017_0512 (2) 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: �333 ��S�Sid E CONTACT PERSON/PHONE: S�!`v�.�- �K�/ko9 Z '�'7t- 673 LOCATION OF SERVICE: �333 �TS�e2 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 ❑Double Check-Detector ❑PressureVacuumBreaker '7Spil1-Resistant Pressure Vacuum Breaker Manufacturer W��s Mode1 Number �7��- Size ``� � Located At /n�� 7�'�� 7 Serial Number �3�'��ti'7 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Y�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��2 psid Opened at 3:� Opened at Held at Initial Test Closed Tightk?� 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 Closed Tight❑ Closed Tight� psid psid psid Test gauge used:Make/Model �W ��"S SN: �r t 7 O S6 O Date Tested for Accuracy: 3 �Z3 -l7 Remarks: The above is certified to be true at the time of testing. FirmName Ului'7� m��'` Firm Address �`5��o p[�R-iue � - da�hs ��3 Certified Tester rint �r �°^� Certified Tester(si nature)� ��tzi� L� • �� .— �P ) g Firm Phone# �� 3�� Q 30� Cert.TesterNo. '�� d�� S� Date ��2-�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 IRRI6ATION 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: ��33 C�'�a.STsi�1�. CONTACT PERSON/PHONE: S��-V��- P�N/Cod R7 Z 71—F16?.� LOCATION OF SERVICE: 1333 CI�STS>o� 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 C�uced Pressure Principle rlReduced Pressure Principle-Detector L�DoubleCheckValve �1Double Check-Detector �lPressureVacuumBreaker �'Spill-Resistant Pressure Vacuum Breaker Manufacturer ��Lk�N s Model Number 47S'XL Size �`� I Located AtN1� R�� A i�'�- ��6 Serial Number z/`�25(�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �.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 �� psid Held at�'6 psid Opened atz'� Opened at Held at Initial Test Closed Tight� Closed Tight '� psid psid psid Leaked'� Leaked'��i Did not open '`1 Did not open ❑ LeakedL 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 I'►'1 W 8'�sy S SN: d I� 70S6D Date Tested for Accuracy: .�-�� —r7 Remarks: The above is certified to be true at the time of testing. FirmName Uw�'T�t4 ��1�� Firm Address ��s�o �LAy�to RO - d41..th� T�C. �5��3 Certified Tester(print) � ��5�� Certified Tester(signature) c� Firm Phone#z�� l —9 j� Cert.Tester No.,$P 0o I/o S,S Date s-(2�'f� *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC ✓ FIRELINE The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS LD. #0570040 (Customer) MAILING ADDRESS: �3 33 �,Q�TSiQ� CONTACT PERSON/PHONE: Lv�A- �'�k-a.0 '�172 ZI�— gb7,� LOCATION OF SERVICE: 1333 C�R+�-fTSfD� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY C�duced Pressure Principle ❑Reduced Pressure Principle-Detector ❑DoubleCheckValve '�Double Check-Detector �PressureVacuumBreaker '��Spill-Resistant Pressure Vacuum Breaker Manufacturer �1'T1rS Model Number ��9 Size �`Z�� Located At �u�'!� /-�e�S� R"�• �7Z' Serial Number ��Z'�$� 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 ]st Check 2nd Check Held at7`Z psid Held at�j a psid Opened at 2''�' Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked� i 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 i� Closed Tight n psid psid psid Test gauge used:Make/Model �� s SN: �!� 7�560 Date Tested for Accuracy: ;3 -- �3 —/7 Remarks: The above is certified to be true at the time of testing. FirmName U/•J fT�'v0 /►1K'-��A��C� Firm Address ��s�o 1�t�-Nc�,QB • ,Q�l1,E-S '7�2�,� Certified Tester(print) �'T �sO� Certified Tester(signature) � Firm Phone# z�`� 3��'� Cert.TesterNo. �O C301/G S',� Date ��Z `�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