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2017_0607 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: �C� �' V �� - `�.:t � O U CONTACT PERSON/PHONE: U �. +n^� a� �o ... 6� . LOCATION OF SERVICE: ( � 3 0(� • 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 CiPressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker Manufacturer ��t� Model Number��q �'�`- Size ! Z— Located At ►� r � (-�v � u� �1.�1�;� Va lh, erial Number /7 �v� �' � 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 �.S S. � Held at�ps� Held at�psid pened at . ' Opened at Held at Initial Test Closed Tight� Closed Tight ' psid psid psid Leaked� I Leaked'�-�' �_ g. Did not open ❑." Did not open I J Leaked❑ Repairs/ Materials Used Held at psid Held at ' psid Test After Opened at Opened at Held at Repair Close ight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model /`�f��c.�,,..e�- ��C�--S SN: I�G �/�/G�/ Date Tested for Accuracy: �� (/�� /�j Remarks: The above is certified to be true at the time of testing. Firm Name �� .T��i r-�- Firm Address �3�;� //��cr��f- Q+�' . �— , u Certified Tester(print) l�' �p ��2 Certified Tester(signature) —.- • Firm Phone��L-�� '�3�'�° Cert.Tester No.��(,��,�5� 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 I.D. #0570040 (Customer) 1 MAILINGADDRESS: \��i. � +�� . �U� � '� � CONTACT PERSON/PHONE: �p. vr�i �. ��'c�� b- �9�*- LOCATION OF SERVICE: ��S .� i I;;rv- "�- 't�3 os 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 C iReduced Pressure Principle-Detector i-1 Double Check Valve ❑Double Check-Detector �PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �1,,('ti'�!S Model Number �� Size ��y '�- Located At t1`��, ^s(� � ts � �' W4�kiw�.Serial Number ��O �j 3(S 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 ��S Held at psid Held at r�psid Opened at Opened at� Held at .�.Q Initial Test Closed Tightl_] � Closed T�ht ��l psid psid psid ��'�,�� Leaked� I Leaked� Did not o n ❑ Did not open ❑ Leaked❑ Repairs/ Materials Used Held at psid ld at psid Test After Opened at Opened at Held at Repair Closed Tight❑ Closed Tight� psid psid psid Test gauge used:Make/Model ��t C� Gcl�-S'� �-(�" � SN: `�G�7' ��a�/ Date Tested for Accuracy: ��` � G/ — / � • Remarks: The above is certified to be true at the time of testing. / � Firm Name 1 A `D ��Z Firm Address � ��L! G �� Certified Tester(print) I ` �� ,'�n�v5�T Certified Tester(signature) (� " � Firm Phone#��1�2)��—-�13�-a , Cert.TesterNo.�6�U '15-5�6 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 �RRIGATION 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) 1 � MAILING ADDRESS: Q�� _� `.� �''�. �� • `��Q . CONTACT PERSON/PHONE: � �� • `�-c�G� � �,� - LOCATION OF SERVICE: ��_-�-5 .2 ��. �. �'?�c��p 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 ��IDouble Check-Detector [t'�ressureVacuumBreaker -�Spil1-Resistant Pressure Vacuum Breaker Manufacturer �C��t-t-S Model Number ��('�)08 J`�CC�' Size� ��c i�2r_ Located At �c �c�t O�. r f 0�� tt( I(��Serial Number (�(j o�� 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 1 st Check 2nd Check �C�S Held at psid Held at psid Opened at Opened at ��'� Held at� Initial Test Closed Tigh �� _ Closed Ti t ��l psid psid psid � —�—� Leaked❑ Leaked�7 Did not open � Did not open u Leaked� Repairs/ Materials Used Held t psid Held at psid Test After Opened t Opened Held at Repair Closed Tight��'1 Closed Tight❑ psid , psid psid Test gauge used:Make/Model `"�i C�l,�r.e� ��lS---� SN: �O�d�7"��/ • Date Tested for Accuracy: ��T d cl� ��D . Remarks: The above is certified to be true at the time of testing. FirmName �� /1 �tJS��-�S• Firm Address 1 3 �� j^9�d�� /� , Certified Tester(print) , O=c2Certified Tester(signature) � � Firm Phone# �"r �Z-� 7?�e,d.�-- ��0 Cert.Tester No. � 6 �SS�� Date �'�� Zz *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: �� . � � �� . �v i , � CONTACT PERSON/PHONE: 0.��' �+�� (p � `0 5 � 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 CiReduced Pressure Principle-Detector ❑DoubleCheckValve �Double Check-Detector C�Rressure Vacuum Breaker !_:Spill-Resistant Pressure Vacuum Breaker , L� li Manufacturer`�I �-�S Model Number G�� ''�� Size� Ld�te✓`� Located At ��-ac�.��io�� '� CJ �'��"�Serial Number �� ( � �� 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 l st Check 2nd Check ��SS Held at psid He at psid Ope, d at Opened at o�� Held at� Inirial Test Closed T' ht❑ osed Tight ��l psid psid psid (�� Leaked _ ,�Leaked� Did not open �� '� Did not open ��' Leakedi l Repairs/ Materials Used Held at psid Held a psid Test Aft Ope�ted at Ope d at eld at Repair Closed Tigbt G Closed Tight❑ psid psid � psid Test gauge used:Make/Model /"�� (��5�- ��,$'—S- SN: %� 7Z"��C��/ Date Tested for Accuracy: t �'v `�--�� , Remarks: The above is certified to be true at the time of testing. �--. �� ' Firm Name � �• .� �uS n'1'-e.�, Firm Address � ��-5� �/ �y�'(� t ''� Certified Tester(print) � A n(��lJ �!'�ic 2 Certified Tester(signature) lG Firm Phone#��Z �� 3.--�I .''L_Cert.Tester No.�+�Q DU�{.S3"� Date �o'"�—�� *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