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2017_1116 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: ('jc�3 t�ran ��-�{ �� x CONTACT PERSON/PHONE: _ v i ' -Z14-49ro� O 0 LOCATION OF SERVICE: lgS^ c,e� ar �-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 '-1Red�►ced Pressure Principle-Detector ��fDoubleCheckValve 'Double Check-Detector !lpressur�VacuumBreaker -!Spill-Resistant Pressure Vacuum Breaker Manufacturer 1��-ebC.c� Model Number $b D Size Z�� Located At � - a� c,h� Serial Number l�y ��{' Is the assembly installed in accordance with manufacturer recommendations and/or local codes? e 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 Opened at Held at Initial Test Closed Tight � Closed Tight i JF psid psid psid Leaked� I Leakedl I 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 Ciosed Tight i I Closed Tight I psid psid psid Test gauge used: Make/Model ��"�� '�z� �L SN: �g� Date Tested for Accuracy: �� '� ��7 Remarks: The above is certified to be true at the time of testing. Firm Name �� —�� Firm Address 3 ��--t\r � P�l , � � Certitied Tester(pr�nt) �L'�U i G� ►�t�l__ Certified Tester(signature) Finn Phone# 2�� -�79�-�� Cert.Tester No. �P0�67s S Date �� /�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 r FIRELfNE The following form must be completed for each assembiy 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: I3�3 Ct �2✓' �i �� T CONTACT PERSON/PHONE: � ' Z�`'f- '�p 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 '_'Red�iced Pressure Principle-Detector � I Double Check Valve ��:��'��Double Check-Detector ' IPressur�VacuumBreaker -�Spill-Resistant Pressure Vacuum Breaker Manufacturer l,.�al`T`� Model Number 00`7 Ir1'1 1 Q'T Size Zr Located At V �5 i'E'c�' ��e��u� 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 1 st Check 2nd Check Held at ��Z psid Held at I�`7 psid Opened at Opened at Held at Initial Test Closed Tighfl`n Closed Tight 7� psid psid psid Leaked 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 Closed Tight! I Closed Tight� I psid psid psid Test gauge used: Make/Model �m�� `�a�c�� SN: �� Date Tested for Accuracy: 9�/$ �7 Remarks: The above is certified to be true at the time of testing. Firin Name �� -�—� Firm Address ��3 ��n /�'� ��✓ � � ' Certitied Tester(prart)�U�d - 1 �Certified Tester(signature) � �[ ,i q ,r Firm Phone# 2�"I �`T l��`'�� Cert.Tester No.��g Date �� P �� * 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 IRRIGAT�ON 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 recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: ( 3b (y,� l E'�' �r�r" 1 �T7� CONTACT PERSON/PHONE: t Z�`F—� �80`�O LOCATION OF SERVICE: t�b� � e�rl�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 : IReduced Pressure Principle '-':Reduced Pressure Principle-Detector yCGDoubleCheckValve Double Cl�eck-Detector f I Pressur�Vacuum Breaker i Spill-Resistant Pressure Vacuum Breaker Manufacturer (�.�0.}-�S Model Number C:l�`]r�')/ Q'T Size Z�/ Located At /Y1 Ll ��t�� u r�vS�- '�/�- Serial Number �S� ��o� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��S Reduced Pressure Princi le Assembl Pressure Vacuum Breake►- � Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �� psid Held at 1,7 psid Opened at Opened at Held at Initial Test Closed Tight'�f Closed Tight M psid psid psid Leakedl I Leaked'�� I Did not open � I Did not open � 1 Leaked I Repairs/ 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 �-jD�°''��z� ��'" ��K SN: z�� Date Tested for Accuracy: �1�/Fl l 7 Remarks: The above is certified to be true at the time of testing. FirmName �-6�//y� Firm Address c� � F'l 1 C-�+�i� � ' 1 T Certit7ed Tester(pr�rt) � �Certified Tester(signature) Firm Phone#�� '��10 �U`!U Cert.Tester No. �rfkj��],s� Date�J ��D�� *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yel(ow-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) n MAILING ADDRESS: f 3Q3 wc�anc��Y' ��r l.c� �) �� CONTACTPERSON/PHONE:17a��d � �4�4 � �O LOCATION OF SERVICE: 143c S� (.J a. ct�+ 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 '-�Redziced Pressure Principle-Detector )bDouble Check Valve Double Check-Detector ; I Pressurc Vacuum Breaker -?Spill-Resistant Pressure Vacuum Breaker Manufacturer WQ�'�5 Model Number ��7/�I/ � Size 'Z�� / � Located At /�G 1�+ u r��S� �/CK Serial NumbeiN g � ��D 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 (csrpsid Held at �� psid Opened at Opened at Held at [nitial Test Closed Tight�'v Closed Tight t�t psid psid psid Leaked! I Leaked' ; Did not open i Did not open ! Leaked I Repairs/ Materials Used Hcld 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 � bra�C..l� `7��—Z��T� SN: Z�BD� Date Tested for Accuracy: � �g�/� Remarks: The above is certified to be true at the time of testing. Firm Name l�9Ppe�� .�� Firm Address 13�3 �(22� l��i� � e�l , � Certitied Tester(prir.t)�ZV '� Certified Tester(signature) � Firm Phone# ��7"f��`'rv Cert.Tester No. `(��_Date �� l 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 � 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 recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) I MAILING ADDRESS: �3�3 �r`� ler ��' e� - �� X CONTACT PERSON/PHONE: v i a i Z�`f—4 � d`�� LOCATION OF SERVICE: t$S� , r c1 The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable paraineters. TYPE OF ASSEMBLY ` iReduced Pressure Principle '.1Red�iced Pressure Principle-Detector p(➢DoubleCheckValve !Double Check-Detector ': I Pressure Vacuum Breaker l Spill-Resistant Pressure Vacuum Breaker ��► Manufacturer �Q .$ Model Number t��/ � Size Located At /`-�D/�'1� �tQQ1l�Lu/!Z 5!C/� Serial Number ��S ' I Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Ye� Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly � Relief Valve Air Inlet Check Valve 1 st Check 2nd Checic Held at ��5 psid Held at �r 7 psid Opened at Opened at Held at Initial Test Closed Tight'�' Closed Tight i14 psid psid psid Leakedl I Leaked!1 Did not open � I Did not open ! Leaked I Repairs/ Materials 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 �Mb�� '��T��- SN: ��Q� Date Tested for Accuracy: �/T/7 Remarks: The above is certified to be true at the time of testing. Firm Name �'�(� L� Firm Address �� t^Ot �CrL.,�'� �I * Certified Tester(print)� � l Certified Tester(signature) � �, Q Firm Phone# Z�� iJ�� Cert.Tester No. F�P�� Date /� �� 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 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 3 0.3 n � � `-o �� CONTACT PERSON/PHONE: u � ' -� (o ' D�L� 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 iReduced Pressure Principle -!Red�iced Pressure Principle-Detector i1�Double Check Valve i Double Check-Detector i IPressur�VacuumBreaker -1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �Ct�s Model Number ��`�/I'1/ �_Size �� Located At!-{p/17e- �f'Q a�+�uh'► '�!G(�- Serial Number K �D�s3 Is the assembly installed in accordance with manufacturer recommendations andlor local codes? e Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly � Relief Valve Air Inlet Check Valve i st Check 2nd Check Held at �'�O psid Held at l,(o psid Opened at Opened at Held at Initial Test Closed Tighti 0� Closed Tight KI psid psid psid Leakedl I Leaked(I Did not open i Did not open ' ! Leaked I Repairs/ 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 l�vi'r►��z�� 0"'Z��'� SN: z�� Date Tested for Accuracy: � /8�/7 Remarks: The above is certified to be true at the time of testing. Firm Name �Ap��l �� Firm Address (? W��'1 �c°t� l�r�/ �, r . Certified Tester(pr�rt)�.0� Certified Tester(signature) � '` D � /�,�� tr�/��/7 Firm Phone# �7'�`'1"9� �� Cert.Tester No.�(�(�l_�� 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 � FIRELfNE The following form must be comp(eted 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: �3�3 i.�rarXlP� C+�r o I( X CONTACT PERSON/PHONE: 1`�ui CI Qaai e�-f ��4—`��o -$D`t a LOCATION OF SERVICE: ($s (,�� c,r�cwl 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 IReduced Pressure Principle '-1Reduced Pressure Principle-Detector ,�Double Check Valve 'Double Check-Detector ; I Pressur�;Vacuum Breaker -t Spill-Resistant Pressure Vacuum Breaker r Manufacturer ()..�t1l�S Model Number �`J7 I`�1 � QT Size Z� Located At �nR��S �f�/ Serial Number �� o Is the assembly installed in accordance with manufacturer recommendations and/or local codes? `��5 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 ��7 psid Held at 2�y psid Opened at Opened at Held at Initial Test Closed Tight� i Closed Tight � I psid psid psid Leakedl I Leaked' I Did not open � i Did not open ' ! Leaked I Repairs/ Materials Used Test After Held at psid Held at psid Opened at Opened at Held at Repair Closed Tight I Ciosed Tight I psid psid psid Test gauge used: Make/Model �MU�� '� ��'� SN: �-��p�a Date Tested for Accuracy: � rb`//7 Remarks: The above is certified to be true at the time of testing. FirmNamel�s'�J��r� �� FirmAddress �3� �� °✓ ��r l.�O �� T� , � \ Certitied Tester(print)�vid��j Certified Tester(signature) � Firm Phone# �l� ��9�C—�O�U Cert.Tester No, r 7 �� Date /� /� �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 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: I30 (��Cl / `r 2�I 1 CONTACT PERSON/PHONE: id a�� - �{q �SO�I- LOCATION OF SERVICE: (�S !.J• ar�c.a�..� 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 '-IReduced Pressure Principle-Detectar �PDoubleCheckValve 'Double Check-Detector ' I Pressur�Vacuum Breaker -,Spill-Resistant Pressure Vacuum Breaker Manufacturer�Lp Model Number �5�1� Size 7-�� Located At � D F 1�cl��r �urp osE'-- Serial Number �f b69/9 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 AssemUly � Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at ZP � psid Held at �� 7 psid Opened at Opened at Held at Initial Test Closed Tighti i Closed Tight I 1 psid psid psid Leakedl I Leakedl � Did not open � i Did not open ! Leaked' I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Ciosed Tight' I Closed Tight� ! psid psid psid Test gauge used: Make/Model l., r' CD �� -�4� SN: �� Date Tested for Accuracy: r /� /� Remarks: The above is certified to be true at the time of testing. Firm Name ��ll �� Firm Address �c��J �lt7/1 /E� � � � t/ " Certified Tester(print) U) l Certified Tester(signature) � ,I II QD Firm Phone#__ �`f �`�f 9�`�� Cert.Tester No. 4.�f�� Date �I/1�l�� *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: (3�3 t,� n �� -o el� 1�1C CONTACT PERSON/PHONE: i�I . � Z.! -'�'1'��30 O LOCATION OF SERVICE: i or' 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 ,Reduced Pressure Principle ':Reduced Pressure Principle-Detector �47Double Check Valve iDouble Check-Detector 1Pressur�VacuumBreaker -?Spill-Resistant Pressure Vacuum Breaker , 1 I z�/ Manufacturer (,��-i;5 Model Number �d7/n� Q� Size Located At�P V1 i� ��,�i-i �urp��+�- Serial Number �10�91`� 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 z�Z psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tight!yF Closed Tight ik# psid psid psid Leakedi I Leaked! I Did not open i Did not open : Leaked I Repairs/ 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�pi'Y►bl'QC-l.� `��—�� /� SN: Z�SQDa� Date Tested for Accuracy: 9�l�1/7 Remarks: The above is certified to be true at the time of testing. Firin Name ��e1� J- � Firm Address ��3 l.�J� ed ��/� � Certified Tester(pranr) � 1t Certified Tester(signature) � ^ Firm Phone# Z•/7 �7 7 b��p 7�� Cert.Tester No.�/�� Date �� /�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 Conv IRRIGATION � DOMESTIC FIRELINE The following form must be completed for each assembiy 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 303 fr�rZtv�C�lE'r �+ � pf�'e-�� lX CONTACT PERSON/PHONE: �cL�i d c,,� �, 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 paraineters. TYPE OF ASSEMBLY ` IReduced Pressure Principle -!Reduced Pressure Principle-Detector �4DoubleCheckValve ' �Double Check-Detector i IPressurcVacuumBreaker 1Spil1-Resistant Pressure Vacuum Breaker Manufacturer i`er�7�-� Model Number $`� � Size Z�� Located At l en n�S �£� Serial Number 1-� �J�}37 S� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e5 Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly � Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �� psid Held at ��`� psid Opened at Opened at Held at Initial Test Closed Tight� i Closed Tight �1 psid psid psid Leaked l I Leaked; I Did not open i Did not open ! Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' I Closed Tight' ! psid psid psid Test gauge used: Make/Model �/►'��/'A� `YD'�2U�%� SN: `ZS �d Date Tested for Accuracy: eI ��/� Remarks: The above is certified to be true at the time of testing. Firin Name(��G�/ LS� Firm Address ��03 Lc�r�tn9/P� �--t� Certitied Tester(pr�nt)� � 1 Certified Tester(signature) , � �/ / ,l,�, p Firm Phone# ��7 '��f lv �"��`�(..' Cert.Tester No. j ��7�Jg Date �l/�� *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION � DOMESTIC FIRELINE The following form must be completed for each assembiy tested. A signed and dated original � must be submitted to the public water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: 13�3 (1�rarLg�ee� ��,� CONTACT PERSON/PHONE: id ui I Ll`f-`�`1�- �f b LOCATION OF SERVICE: ($� Par �•�� 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 '.-1Reduced Pressure Principle-Detector !�4DoubleCheck Valve Double Check-Detector f IPressurc;VacuumBreaker -iSpill-Resistant Pressure Vacuum Breaker Manufacturer �e��U Model Number g`�� Size Z�� Located At �r'� d� S C�� Serial Number N �'�s�� l, 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 Z+�psid Held at Z• d psid Opened at Opened at Held at Initial Test Closed Tightf i Closed Tight I l psid psid psid Leakedl I Leaked' I 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� I ClosedTight'� I psid psid psid Test gauge used: Make/Model �M b�� `�O-�� SN: 'Z��a Date Tested for Accuracy: �� $I �1 Remarks: The above is certified to be true at the time of testing. Firm Name �--0�� -a-S� Firm Address �3�3 �� ✓� Certified Tester rant Ck�`�t�Certified Tester(signature) �� t �P )� � q Firm Phone# ��'�'�" 1�'��U Cert.Tester No. ��7s�Date ��/�� 7 * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy IRRIGATION X DOMESTIC FIRELINE The following form must be completed for each assembly tested. A signed and dated original � must be submitted to the public water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: 13 03 l�-�m (e✓�ir � elI qb gO�U CONTACT PERSON/PHONE: ' av;C� �'� ?�`�-`� LOCATION OF SERVICE: l$'S�(,J � 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 paraineters. TYPE OF ASSEMBLY ` IReduced Pressure Principle -1Reduced Pressure Principle-Detector ;�PDoubleCheckValve 'Double Check-Detector � IPressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker f/ Manufacturer (�.�[�'�"'�S Model Number �O`� fn'1 l �''�T Size Z Located At Lt9e� o� J�-tQ��urrl Serial Number '��U Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��-5 Reduced Pressure Princi le Assembl Pressure Vacuum Breaker � Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at (� � psid Held at �� psid Opened at Opened at Held at Initial Test Closed Tight�" Closed Tight'�1 psid psid l�s�� Leakedl I Leaked' I Did not open � Did not open ' Leaked I Repairs/ Materials Used Test After Held at psid Held at psid Opened at Opened at Held at Repair Closed Tight' i Closed Tight ! psid psid psid Test gauge used: Make/Model l-�m��D �0�zUU (IL SN: �`�� Date Tested for Accuracy: �� 7 Remarks: The above is certified to be true at the time of testing. FirmName �fJf�� s� Firm Address l �.3 �"� �� `-�'�• � Certified Tester(pr�nr) �a V iC�1 1 J�� '�1 Certified Tester(signature) � f Firm Phone# 2�� T 1��&��a Cert.Tester Na UPdCY�67� Date I� ��O �7 * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS �a»,;�A_r�;r.,('nnv Yellow-Customer Copy Pink-Tester's Copy IRRIGATION X 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 3a3 ��t►1 �e'' Ci� �.n� �(� \ CONTACT PERSON/PHONE: i d i�� I'��{9 b —�D4 C' LOCATION OF SERVICE: $ r C� �I 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 '-IReduced Pressure Principle-Detector �DoubleCheckValve '.Double Check-Detector I1PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer�� Model Number ��L` Size Z�r Located At So�.��.. CAS�c' Cfx�n�afi .i�rFBF�'e��erial Number l-� L��bl Z- 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 AssemUly � Relief Valve Air Inlet Check Valve l st Check 2nd Check Held at L�� psid Held at �.�Z psid Opened at Opened at Held at Initial Test Closed TightM' Closed Tight i� psid psid psid Leakedl I Leaked! ; Did not open I Did not open ' ' Leaked I Repai rs/ Materials Used Held at psid Held aY psid Test After Opened at Opened at Held at Repair Closed Tight' i Closed Tight' f psid psid psid Test gauge used: Make/Model M bRxcc3 ��-Z�`l!C- SN: z-�� Date Tested for Accuracy: 1 g 1 7 Remarks: The above is certified to be true at the time of testing. Firin Name ��I I -i— 5.0 Firm Address � D�J(�✓ �� i � � �� / , r Certitied Tester(pr�nr) `CI ��Certified Tester(signature) � '` �/ ,/ Q,� / Firm Phone#��7"7"�� aT� Cert.Tester No.L/► ��p7Sg Date � �T 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