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2017_0627 IRRIGATIOfV 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 recordl<eeping purposes: � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) e-�( �� MAILING ADDRESS: I�� (,J/`0�,1'l�i� �ir ��p CONTACT PERSON/PHONE: G.ouis �a5 �� — 9� "�fd`fb LOCATION OF SERVICE: l Zo -�c�e5 fra[L- 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 14Reduced Pressure Principle !Rediiced Pressure Principle-Detector �� I Double Check Valve !Double Checic-Detector i 1 Pressure Vacuum Breaker �Spi11-Resistant Pressure Vacuum Breaker Manufacturer (,L�-[�5 Model Number C—��Ocl Size ��t Located At �P,Cf'l � �n[°�`�ton �� i'e�d Serial Number O�2-`�(73— p`'7�S� 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 I � �QSrj Held at �� psid Held at psid Opened at 3_ i Opened at Held at i Initial Test Closed Tight' i Closed Tight i I psid psid psid Leaked l I Leaked' I Did not open : i Did not open ' Leaked I I Repairs/ � Materials � Used Held at psid Held at psid � Test After Opened at Opened at Held at I Repair Closed Tight I Closed Tight' I psid psid psid i � Test gauge used: Make/Model Cv�h%� `�"��—Zd�� SN: �$�U� Date Tested for Accuracy: q �� (o I Remarks: i I The above is certified to be true at the time of testing. I Firm N ame - Cc v 1�� >c.x f I Firm A ddress �a� �J�1I't /�i GI�✓ I r r-;nt Ct /t( CertifiedTester si nature �� '' r I Certitied Testc (p ) - (� � �_ P ( g ) � � Firm Phone# Z�� —`C��`�� Cert.Tester No. I�T�� Date ''z7 �� I I * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT PARTS � White-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION DOMESTIC C 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: l 3Q3 l w��ir��e✓' �-t�►'' �A�'-� �� CONTACT PERSON/PHONE: ' �— � t — � (c�--��`f b LOCATION OF SERVICE: I `� ��'� FS �r�c-c-- 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 : iReduced Pressure Principle -!Reduced Pressure Principle-Detector � IDoubleCheckValve !Double Check-Detector I1PressureVacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker Manufacturer i.t�e1�S Model Number L�DC�rf ��[T Size l/Z Located At -K,l't�� Serial Number 7 Z�1�- Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assembl Pressure Vacuum Breaker i Double Check Valve AssemUly Relief Valve Air lnlet Check Valve � 1 st Check 2nd Check I Held at�psid Held at psid Opened at �Z�� Opened at Held at I Initial Test Closed Tight�` i Closed Tight I I psid psid psid Leakedl I Leakedl I Did not open �� I Did not open � I Leaked � � Repairs/ � Materials Used � Held at psid Held at psid � Test After Opened at Opened at Held at Repair ClosedTight 'i ClosedTight ! psid psid psid i Test gauge used: Make/Model��M LJrQ L-G �O�-7-a0�/� SN: �-�4fyZ> ! Date Tested for Accuracy: g��g��re I Remarks: i The above is certified to be true at the time of testing. i Firin Name �l,�/� .-F—� Firm Address f1 I i i / r � Certitied Tester(pi-=nt)��/1� �[ ° Certified Tester(signature) i � `�,, D Firm Phone# — ' �7U Cert.Tester No. T Date �r1 Z7 � I * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT PARTS � White-City Copy Yellow-Customer Copy Pink-Tester's Copy i - __ IRRIGATION DOMESTIC X 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: �b� �►� 'e-� X CONTACT PERSON/PHONE: L..m i 1 aS 2�`� - �- �F� LOCATION OF SERVICE: O I�e �.e— The backflow preveiition 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 }Q�Zeduced Pressure Principle iRed�iced Pressure Principle-Detector ; iDoubleCheckValve 'Double Check-Detector i 1Pressur�VacuumBreal<er �Spill-Resistant Pressure Vacuum Breaker I ' r �� Manufacturer ��tTT� Model Number �-f- D� m-� � Size �� Located At ('.ryn�re ��n �-I-T �a�� Serial Number �z 1�JQ 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 AssemUly Relief Valve Air lnlet Check Valve � 1 st Check 2nd Check P�j7 Held at�,�psid Held at psid Opened at Z�� Opened at Held at [nitial Test Closed Tight i Closed Tight � i psid psid psid Leal<ed'� I Leaked! i Did not open I Did not open � Leaked I Repairs/ Materials I Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i ', Closed Tight' ! psid psid psid Test gauge used: Make/Model�+"�b►�-� ybr Z�Q TIC SN: Z��bDD � Date Tested for Accuracy: 9�fc�/��a j Remarks: I The above is certified to be true at the time of testing. j i� j 1 � I Firm Name� e I -`s� Firm Address 3��1.//'Q �/" �� pp i Certit7ed Tester(pr�^t) U I� Certified Tester(signature) � � � . 'I / ' �1l ,�,�,,�/ j F�rm Phone# �/'t- ��(e�� rU Cert.Tester No.��PfJC�Xn75� Date � �7 * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT PARTS � White-City Copy Yellow-Customer Copy Pink-Tester's Copy I