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2017_0925 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: I 30� �,,�rc��P� ��f � �p r��-I I � CONTACT PERSON/PHONE: Lew�S (�1.cic►'a Z ``{ - `�q� - F�O`-�'b LOCATION OF SERVICE: C 303 t.*��,«v�� ej' �-';� The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable paraineters. TYPE OF ASSEMBLY I'9�Reduced Pressure Principle -Reduced Pressure Principle-Detector I Double Check Valve Double Check-Detector rpressureVacuumBreaker -Spil1-Resistant Pressure Vacuum Breaker Manufacturer �Ci'��S Model Number �-r�� Qr Size i�Z,� Located At 17 M �o��e Serial Number (EX�1�1� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e5 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�psid Held at psid Opened at Z�S Opened at Held at Initial Test Closed Tightrl Closed Tight �_ psid psid psid Leaked.I 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 ClosedTight��7 ClosedTight :� psid psid psid l�p��o�rK Test gauge used: Make/Model �o�"��`"��-o "� SN: zs�Ov Date Tested for Accuracy: /�/�l �7 Remarks: The above is certified to be true at the time of testing. Firm Name� ��l � S D Firm A ddress �� W t`U�A L�PJ' l�t r Certified Tester(pr:nt) � Certified Tester(signature) �a tJi`��EJO�► �l�1 Firm Phone# �ZI`i"-�� v�U Cert.Tester Na�PD��ls C� Date � ZJ�' � ? * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-Ciry 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: ��J03 t�ro�ntiPr' ��r �nn�� T'1� CONTACT PERSON/PHONE: Lou�S Matir�S LOCATION OF SERVICE: 13v3 (,��,,y�S�� G`r 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 �4Double Check Valve "Double Checic-Detector !lPressur�VacuumBreaker Spill-Resistant Pressure Vacuum Breaker Manufacturer �Qh� Model Number �3��(� Size 2�� Located At N�*�'�-�� o-� S�rv?r.�.-Cp._.r��'" Serial Number �-� 0 t4�rl 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 '2`� psid Held at �i�psid Opened at Opened at Held at Initial Test Closed TightlYl Closed Tight i)4 psid psid ps�� Leaked! I Leakedl I Did not open � Did not open : Leaked ! Repai rs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight' I ClosedTight' I psid psid psid Test gauge used: Make/Model�M�t�o<<-.o �'0""z�p�� SN: ZSSp� Date Tested for Accuracy: �1�8' 1�1 Remarks: The above is certified to be true at the time of testing. Fir�n Name ��e�� 5� Firm Address 1��3 �t��.1/� 1 r �i i'• Certified Tester(pr:nt)�O�V i c� ca��Certified Tester(signature) a Firm Phone#� �� ``t��"�d � Cert.Tester Na DPDC�d�ZSS Date `1 �5 f * 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 FIRELfNE The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordlceeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) 1 MAILING ADDRESS: �303 ►^c�n f � �.o � CONTACT PERSON/PHONE: l..o�t�5 t-i Z� —4 — n`� LOCATION OF SERVICE: 13b�� l�cc�.v��e.►r' 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 '-1Redeiced Pressure Principle-Detector �Double Check Valve '�Double Checic-Detector i I Pressure Vacuum Breaket- �Spill-Resistant Pressure Vacuuin Breaker Manufacturer WQ'�'� Model Number �d� �� Q► Size Z�r Located At weST �'f s��- �/��' Serial Number /T �� 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 AssemUly Relief Valve Air lnlet Check Valve 1 st Check 2nd Check Held at Z r`� psid Held at 'Z,.� psid Opened at Opened at Held at (nitial Test Closed Tight'iX Closed Tight I� psid psid psi� Leakedl I Leaked i Did not open � I Did not open ! Leaked '� Repai rs/ 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 l�M�rt1.Co �0 - �� "�—SN: Z�� Date Tested for Accuracy: �''1 �l$�'-7 Remarks: The above is certified to be true at the time of testing. Firm Name l.o�JG�� r--�J� Firm Address ��b�3 W'CG��IQ1'' �,r, r � � Certitied Tester(pr�nt)D lAt�I �[�Q Certified Tester(signature) Firm Phone# Z( � —�� "��4d Cert.Tester No.�P�� Date ��5 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 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 recordlceeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) /� MAILING ADDRESS: 1303 �,-a,n��e►' �'r, l..�p�el� CONTACTPERSON/PHONE: �0��5 ' Z1 - � b - p�(v LOCATION OF SERVICE: 13G3 i,�+'b:vlq 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 �DoubleCheckValve !Double Check-Detector ! IPressureVacuumBreaker -�Spil1-Resistant Pressure Vacuum Breaker Manufacturer r�t,t� Model Number �S G Size '� r� Located At �02�N pF S�R.�JY'C.�-CetJ►EYL Serial Number �(�(a�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �eS 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 ��`1 psid Held at�psid Opened at Opened at Held at Initial Test Closed Tight!`� Closed Tight �1� psid psid psid Leakedl I Leaked! 1 Did not open i Did not open ! Leaked '� Repai rs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' I Closed Tight' I psid psid psid Test gauge used: Make/Model ��7rv.c-t� �D��O�jL SN: ��g�� Date Tested for Accuracy: q� I$ 11 Remarks: The above is certified to be true at the time of testing. Fir�n N ame �D Q��'�' ��p� Firm A ddress ��3 �r�t r1 y l�i� �r'r � / r .q Certified Tester(print) Y�aU � � � � Certified Tester(signature) �� `25 Firm Phone# 7_I_�{=C�q��-�(�`�d Cert.Tester No. �PQQO�O7s� Date—��/i��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