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2017_0609_RPZ 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) t ,, � MAILiNG ADDRESS: 1�� `�Y� ��. ��i� � � , CONTACT PERSON/PHONE: Y� ;-� . �o(o ° C� �s LOCATION OF SERVICE: ��D"�� 5• �2,( �� `�3c� 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 I�educed Pressure Principle ❑Reduced Pressure Principle-Detector ❑DoubleCheckValve ❑Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �,��'j Model Number Q��/`��' Size \ ��Z- S�is�� - Located At � ' r�e.n-� �-o \,�: � Sc�� r: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 lst Check 2nd Check ,�.C� \ Held at�psid Held at�psid Opened at�• � .. Opened at Held at Imtial Test Closed Tighti I Closed Tight ❑ psid psid psid �j�—�_� Leakedl�I Leaked❑ Did not open '�l Did not open G' LeakedC� Repairs/ Materials �� Cl T�l ` �V ,.��< �2^� '�c�;r � � � Used � " —q— �'� Held at psid Held at psid est After Opened at� Opened at Held at Repair Closed Tight[ ; Closed Tight❑ psid psid psid Test gauge used:Make/Model �� 2,��" ��-1 S- .5 SN: ��-�� / Date Tested for Accuracy: — Q �' 1 Remarks: t,- �- ' nk✓�i��' h 1� i;�- ' The above is certified to be true at the time of testing. ,. Firm Name � ` �c S �'- • Firm A ddress �3�U � . �- �� t Certified Tester(print) � � �,�r� �C ZCertified Tester(signature) � a� �� , Firm Phone#��Z j��`�t�� Cert.Tester No.�C1�S'� Date � �a�_�—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 The following form must be completed for each assembly tested. A signed and dated ariginal 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: I O S " 2 �t-�� - � �`� �� CONTACT PERSON/PHONE: a f� - �a� � • LOCATION OF SERVICE: /o�4' S � %�/,i-� � . �'300. 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 �Zeduced Pressure Principle �1Reduced Pressure Principle-Detector ❑DoubleCheckValve �Double Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer ��,5 Model Number �� T Size l �Z � 1 i r �r �t �� ( Located At ��5�c�-G �v t �� ,�� tv �� 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 1 st Check 2nd Check �fs Held at�psid Held at �� ps' Opened at � � Opened at Held at Initial Test Closed Tightf� Closed Tight psid psid psid �_ �_�� Leaked'-] Leaked� Did not open � I Did not open Leaked❑ Repairs/ � Materials Used �� Held at psid Held at psid , Test After Opened at � Opened at Held at Repair Closed Ti�ght C: Closed Tight��i psid psid psid Test gauge used:Make/Model ��il25� ��-S �� SN: ��G � �y6�/° Date Tested for Accuracy: �f' �c/ �� • Remarks: The above is certified to be true at the time of testing. Firm Nam��F � �S T'' � Firm Address �.� �S� !�'��rY��'� �Z, s � Certified Tester(print) � � � Certified Tester(signature) / Firm Phone# �(�� 4" �� Cert.Tester No./,�''��d(1�S.S C� 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) ` MAILING ADDRESS: O�S `� � � � �1 . ��'� �� CONTACT PERSON/PHONE: Q �:>r.-�" (.� . �'� ^� LOCATION OF SERVICE: l 0�1-� �. (2,_,� � � � � . 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 f�Reduced Pressure Principle ��Reduced Pressure Principle-Detector ❑DoubleCheckValve �lDouble Check-Detector :-7PressureVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker � 1 � Manufacturer �� S Model Numb r (�b� �02 C�' Size � �'Z- ��S�M Located At i � '�o uscn�e.✓'��+�'Serial Number � 3� � � �' 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 u S 5 Held at �` 1 ps Held at ��psid Opened at p�� Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid (p-}—��- Leaked� Leaked� Did not open r Did not ope ❑ Lea d❑ Repairs/ Materials Used Held at sid Held at psid Test After Opene at Opened at Held at Repair Closed Tig ❑ Closed Tight � psid psid psid Test gauge used:Make/Model /�(/ C�4�.e� ��S-°'� SN: �� Y � Date Tested for Accuracy: j�� - f � Remarks: The above is certified to be true at the time of testing. Firm Name � G l [I�"D �� Firm A ddress �� 1 i � a� �Q• � o Certified Tester(print��,�✓►�,S�i�- Certified Tester(signature) �"—' 4 Firm Phone#��` �3 �O Cert.Tester No.�/'!�/d�SS� 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) I MAILING ADDRESS: �� - �. d• �L� �- L70 CONTACT PERSON/P ONE: ° �OG -- �C�� LOCATION OF SERVICE: 'w•— �' �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 f�'Reduced Pressure Principle �Reduced Pressure Principle-Detector ❑DoubleCheckValve �IDouble Check-Detector ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker ��r Manufacturer ��_�-�� Mode1 Number ��q�o�.�• Size .._, '��o �?• �� ir-��o�� 'S Located At ` �o\o..�;; �.°� �Y ��`�n.�cci�Serial Number � .�� f• 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�.G�S r� Held at��oZ psi eld at��D psi pened ato<•� • Opened at Held at Initial Test Closed Tight!. . Closed Tight '�_ psid psid psid �'j-- �-_�� Leaked�� Leaked� Did not open C� Did not ope C:� Leake I Repairs/ / Materials Used � � Held at � psid Held at psid ' ' Test After OpetYed at Opened at Held at Repair Closed Tight❑ Closed Tight❑ psid psid psid Test gauge used:Make/Model �(/ir Q�(,�f 25�' '�/�—� SN: ��(�'� / rl� � Date Tested for Accuracy: �� f'f— �(G • Remarks: The above is certified to be true at the time of testing. FirmName I� Ct�tO'�� /E'��2 Firm Address �3��0 �+Pfo ryt� ,!/,�. �/— J Certified Tester(print) ��• L�i�US�'��Certified Tester(signature) •- � Firm Phone# `�� U�B�Q,� ��Cert.Tester No.I�P.ODO gSS� 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 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) i � MAILING ADDRESS: \� S � . t�a .� �� ''� � �� vc� CONTACT PERSON/PHONE: c� � �� F ��6 �� LOCATION OF SERVICE:� - ��r� v� 36�' � 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 ❑PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer ��Q��,-5 Model Number ('� � �� — Size� r VJ0.lM.�r�.� . . Located At(�/� 7 rc�e��c.�n{�� U�� k 1��Serial Number ��S�� ' Is the assembly installed in accordance with manufacturer recommendations and/or local codes? CS. Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check �<S.5 /� p� Held at "1`� p�id Held at 1•Q ps��d Opened at� Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid �_�_(� Leaked�] Leaked'��1 Did not open !� Did not open I i Leakedi Repairs/ Materials Used Held a psid He d at psid Test After Op, ed at Opened at Hetd at Repair Closed Tight'i I losed Tight!� psid psid psid Test gauge used: Make/Model�i` Ccf e5r�— �(��` SN:��G ��y Date Tested for Accuracy: /�` O �— � �v Remarks: The above is certified to be true at the time of testing. FirmName � �' `5 �/�• Firm Address �.3�5�j ��i,t��oMt�T �� 'o Certified Tester(print) �� '' �t�Certified Tester(signature) . �A Firm Phone# �2� ��;�'/3� Cert.Tester No�+�l:�Srs 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