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2017_0531 IRRIGATION DOMESTIC FIRELINE ,f�/ 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) r� a� r�-�� ! MAILING ADDRESS: J�Q � CONTACT PERSON/PHO : i h � OrJ'T �' 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 ❑Ij,educed Pressure Principle `�Reduced Pressure Principle-Detector ��oubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker USpill-Resistant Pressure Vacuum Breaker ��LI�1P.t�v�A/ ��l�`— o�, Size e� Manufacturer Model Number Located At..U� ��►ti�8.� Serial Number 3 $7a��9 Is the assembly installed in accor ance 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 �� psi Opened at Opened at Held at Initial Test Closed TightC� Closed Tight � psid psid psid Leaked.� Leakedi�� Did not open � Did not open ❑ Leakedl� Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight C` psid psid psid Test gauge used:Make/Mode16/��Y'� � 1 ��5 SN: o�?Q ! �� Date Tested for Accuracy: 7,�a/�t� Remarks: The above is certified to be true at the time of testing. Firm Nam��JA. Firm Address�at�O��,��.�,��,�Q.� �� 7.7o�a� '"(' J Certified Tester(print .0.��Y' U.�'.C Q 6 Certified Tester(signature) Firm Phone# 1 /a�'�� / �� Cert.TesterNoBPDaa�o�� Date��J �w / / *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) � �� ,�,r�-� r�-�� MAILING ADDRESS• � � CONTACT PERSON/PHO E: ' a �n I - O- O 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 ❑lj,�duced Pressure Principle-Detector ❑Double Check Valve F1'l�ouble Check-Detector ❑PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker Manufacturer G�/��t�'YIAJ Model Number35o�S � �a Size�_ Located At../.�1� /1X�A�� 1�.� 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 atf�o�psid Held at4l�ps Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid Leaked'�, ! Leaked��'�'� Did not open ��l bid not open Ll Leaked�i Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight I� psid psid psid Test gauge used: Make/Model M� "*��.11.lLt� ��5 SN: ��D 9D5�� Date Tested for Accuracy: �"'��' � Remarks: The above is certified to be true at the time of testing. FirmNam�l(�i� �.r1p / J Firm Addres�a[c�3��I�D'U.ItEtA�i�GC'y�3�� Q1G�` �J�al'2!� � Certified Tester(print�i Q��' C�EO�y�Certified Tester(signature) Firm Phone#I /�'"��Q''�� 7�� Cert.Tester No�f�OQ�$ 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�C _ 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) �.J MAILING ADDRESS: �R 3 3�,s� � ,��,�v-rv.�C , .� �SOI� CONTACT PERSON/PHO E: � k -Fn� � ' LOCATION OF SERVICE: � �tt 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 �educed Pressure Principle �1Reduced Pressure Principle-Detector �_ ouble Check Valve �-1 Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer �� Model Number d JD Size�— Located At��t,�Ct9�U �1 rn2.�'�� Serial Number 11 D 58�d 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 Held at 01�a( psi Held at�ps' Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight u psid psid psid Leaked❑ Leaked��1 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 ClosedTight� ClosedTight❑ psid psid psid Test gauge used:Make/Mode16/�[,v0c1�:.rZA�c� O'T�� SN: �(A��J o ` Date Tested for Accuracy: / "��' � � Remarks: The above is certified to be true at the time of testing. FirmName( 1� ��',�� Firm Addres��1�D�Q��Z�`��3d� d�k1J� ��`�� Certified Tester(print�(.�Q�P�i^�C@6� Certified Tester(signature) /1J .� Firm Phone#��a��-(�`�I <� Cert.Tester No.Q PC,��l1�0�� 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