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2017_0713 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��yv►.�- ��a A��Qs �z�� CONTACT PERSON/PHONE: � C�LSen l � �- (��3 LOCATION OF SERVICE: l 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 �❑ duced Pressure Principle [JReduced Pressure Principle-Detector ouble Check Valve ❑Double Check-Detector ❑PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker �� Manufacturer �,�.ta."�-S Model Number �C'J/nf Size�_ Located At �iv �'1� �J°1 5��% Serial Number ��"19'�' 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 Held at ��p id Held at��psi Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid RSS Leakedn Leaked�] Did not open �� Did not open '�7 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�� 'a��"7�� sN: B 6r fl 1 g� Date Tested for Accuracy: q—.3 �—'b Remarks: _�/!t� The above is certified to be true at the time of testing. FirmName �� 'Y`ti�� Firm Address .��'� �� J {ac� �T`�Q`��1� Certified Tester(print) p�it�n�� ,o�F2� Certified Tester(signature) Firm Phone#.r��'��/�'�E 0� Cert.Tester NoQ i��J�9'y Date 7"�c�'"�7 *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: R� i ti� �c,.L�i i�� },}�� IQ,s T✓s•zd/ CONTACT PERSON/PHONE: ,' � u - '7 Y 3 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 "1Reduced Pressure Principle-Detector ��ouble Check Valve �Double Check-Detector ❑PressureVacuumBreaker I'Spill-Resistant Pressure Vacuum Breaker ,J �i Manufacturer �GbGG" Model Number ��'� Size �!1 Located At� /'CL-l.v'r �`1��'+'��-�-�y Serial Number ly�� ' Is the assembly installed in accordance with manufacturer recommendations and/or local codes? t°S�- 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 ��o psi Opened at Opened at Held at Initial Test Closed Tight� Closed Tight � psid psid psid � Leaked❑ LeakedJ Did not open C� Did not open �� Leaked'��l 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/Model ��f�a �D'�D�'Tl�,�� SN: ��-�� Z �4(2 Date Tested for Accuracy: 8�31~ �� Remarks: �,�!/L�. The above is certified to be true at the time of testing. � FirmName (�� 1'►�t.L4�� - Firm Address a�6f�oZ /ll�u.��.c� �/ctc'� �� '7sE��j Certified Tester(print) Wf�FA.�y 6o1��L Certified Tester(signature Firm Phone#��-3y�-'7rc� Cert.Tester No�j��f2y'� Date '�1.��7 * 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) �a� ��}. � �j��, �� MAILING ADDRESS: � �� CONTACT PERSON/PHONE: ` ,' Q�.,Se�► 2� " �_ �� 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 �❑ educed Pressure Principle �Reduced Pressure Principle-Detector Double Check Valve �l Double Check-Detector 7PressureVacuumBreaker �ISpill-Resistant Pressure Vacuum Breaker '/ � Manufacturer �,/1�� Model Number �Q'�� Size �! Located At�/`eG.-�'f"�'�.aM�E� bN �'�'��' Serial Number �7J�� Is the assembly installed in accordance with manufacturer recommendations and/ar local codes? G� 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�'�a 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❑ ClosedTight❑ psid psid psid Test gauge used: Make/Model�a 1�� '��'a'� —4l k�lJ srr: d d I l t 1 g� Date Tested for Accuracy: �~.��—�b Remarks: �'1�C�/1p1• The above is certified to be true at the time of testing. FirmName p�S` �11��✓��'�Ct',5��- Firm Address�,'��L!� /�Gv,�ZtMa,' �"�iG� [�'[1��'�'�d�il� Certified Tester(print) �tlft��0 6ory9�z Certified Tester(signature) Firm Phone#.��'�`".3�f` �l� Cert.Tester No�PQL'��y Date 7' 1�' �� * 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 C�IECK ONE: � IRRIGATION DOMESTIC FIRELINE BACI�'LOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # � ffrl QQ� LOCATIOIv OF SERVICE: �� KG�• The bacl�low preveation assembly detailed below has beea testcd aad maintaincd as requircd bv TNRCC reguladons and is certified to be operating within acceptable paramcttrs. TYPE OF ASSEMBLY C/ Reduced Pressurc Principle C Pressurc Vacuimi Breakez � Double Chock Valve � Atmosphere Vacuum Breaker �il Maaufact�er ��t--"� Siu Model Number ��'�I�C�?l4" Located At ��4a� ��P/l /' fi�S�P�/. Serial N�ber �� REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER Doubie Check v alve Assembly lst Check =nd Chec3► Relief Valve Air Inlet Check Valve Inival Test DGClosed �� Closed Tigh� Opened at Opened at osid Tight Leal:ed C• o nsid _,osid �sS Rp__psid �;� p Did not Opea o Leal:ed � �� and Materials Usod Test ARer DC-Closed Closod Tight o ppeaed at Opmed at _nsid Repair Tight o osid �osid RP sid The above is cerdfiod to be tnu. FirmName��.5 ��l`�-C��auY,�.-Ws�, CertifiodTesta tvetF2�D 6ol�ez- Firm Address ` � ` ��a- �- Cert. Tater No.Q ��3�9Y Date .3� r✓ - �n.��l�-�C�� l�d��l Gauge # �'(�(.��(� llate last accuracy tested _ �'�� White- Customer's Copy Yellow - City Copy Pink-Tester's Copy