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2017_0615 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: �^T � , Ca et 1 �'X. �i5o�q CONTACT PERSON/PHONE: �niR Vfl pr1 �Q . 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 f�Double Check Valve ��T�oublo Check-Detector ❑Pressure VacuumBreaker ❑Spill-Resistant Pressure V acuum tsreaker y �i Manufacturer ��}�-'�� Model Number �F(,�7 M��Size�_ Located At �� , Serial Number o��]e��]g Is the assembly installed in accordance with manufac er 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 ' ��ps' Held at�ps� Opened at Opened at Held at Initial Test Closed Tight'�_ Closed Tight � psid psid psid Leaked[� LeakedL� Did not open L� 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��1 psid psid psid Test gauge used:Make/Model j�kt �� SN: �� !� `�� Date Tested for Accuracy: � - Remarks: — .+.� The above is certified to be true at the time of testing. Firm Name ��j� 1Q(,c)�/Firm Address��(,��'��t,p j �j�1eTj�'7�� Certified Tester(print ��Ye � ertified Tester(signature) � Firm Phone#��t-^(9�'9Q�� Cert.Tester No.�P 7�� Date �"��'J � � * 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: „ � I ��j�q CONTACT PERSON/PHONE: v1 V Fi 1 - - LOCATION OF SERVICE: �7 . � ir1 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 �duced Pressure Principle Reduced Pressure Principle-Detector ��'Double Check Valve Double Check-Detector PressureVacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer �+ ��i�Fl S Model Number �� Size � Located At M�� 'v1d �j�Q . Serial Number_ A(,�p 3� 7�� is the assembly installed in accordance with manufactu`�ecommendations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air lnlet Check Valve 1 st Check 2nd Check Held at o��ps' Held at�psi 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 Closed Tight ! Closed Tight psid psid psid Test gauge used: Make/Model �j�[ i 1�1 IRS/ �G-1� SN: � �(� � q,�q Date Tested for Accuracy: � 'a�'J" �7 Remarks: The above is certified to be true at the time of testing. Firm Name��l�rj�� p Y5(.Firm Address��(� l � �i �� ''r�Qa� Certified Tester(pr:nt) � Certified Tester(signature) � Firm Phone# �l�-}—(�?�'�Q�� Cert. Tester No j�3�� Date �i -�_ - �-] * 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 v 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: �7� � ' - Co el 1 T�C. 50 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 ❑R,�duced Pressure Principle �Reduced Pressure Principle-Detector f7��ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker �� Manufacturer�� i g Model Number �7'� ��Size � Located At T ` ,Serial Number '�-�� $� Is the assembly installed in accordance with manufacture recommendations and/or local codes? �� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at � . p ' Held at o�r�psi Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight =, psid psid psid � Leaked�� Leaked�'� Did not open ❑ Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model�i�4G�b�� SN: d$ �d��,�9 Date Tested for Accuracy: Remarks: The above is certified to be true at the time of testing. FirmName p�_Y'ld.��IC,14��[5La1�Vt�irm Address ��,��!�'j,�,< </�1��X'�� Certified Tester(print)��'C'�1�%�ertified Tester(signature) R Firm Phone#��—(�� Cert.Tester No. � Date �o� 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 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) i —�^ MAILING ADDRESS: � , � 2.t� 1 X rI 50 �� CONTACT PERSON/PHONE: r C I � 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 ❑�uced Pressure Principle-Detector ❑Double Check Valve ��'Double Check-Detector ❑PressureVacuumBreaker �',Spill-Resistant Pressure Vacuum Breaker Manufacturer V�[i j�i Y'1� Model Number_��('�S��'}- Size (S!�r Located At�� y� , � Q,Serial Number _ �� 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 .�' psi Opened at Opened at Held at Initial Test Closed Tightl Closed Tight psid psid psid Leaked❑ Leaked�� Did not open ❑ Did not open O 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 YV i��j 1'1��C?!�'l SN: �$ ��Cg��']� Date Tested fo�Accuracy: — �"I K Remarks: — .� The above is certified to be true at the time of testing. Firm NameC��(��i)��f,Firm A ddress �"�� Pe� ��{('�''�f�'�'�(7� Certified Tester(print) � � Certified Tester(signature) � Firm Phone# �1� —��Z 7��Cert.Tester No��('�j37� 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