The URL can be used to link to this page

2016_0224 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) ��.Q,< MAILING ADDRES�, �51� CLLj/► CONTACT PERSON/PHONE: „rn ' o�n(�s u fo'9- (o �q I$S 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 1R uced Pressure Principle ❑Reduced Pressure Principle-Detector C ouble Check Valve ❑Double Check-Detector �1PressureVacuumBreaker �7Spi11-Resistant Pressure Vacuum Breaker Manufacturer �I��j Model Number 0�'� �1 [�_Size a , Located At�nQr�U�OI 1� S�dt vC b�� Serial Number J�O�'D'-` Is the assembly installed in accardance 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 �� psid Held at (�� psid Opened at Opened at Held at Initial Test Closed Tightl� Closed Tight 1►'� psid psid psid Leaked[ I Leaked[1 Did not open ❑ Did not open ' I Leaked❑ Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Neld at Repair ClosedTight CI ClosedTight'�� psid psid psid Testgaugeused: Make/Model ��1—K\►�� `-7 SN: C)311a?dqa, Date Tested for Accuracy: � '�}� ��'S Remarks: The above is certified to be true at the time of testing. FirmName Polk �fecha�c.�„l Firm Address�7�}a5 �►��dlYd $�. �av� �I'ir IX 35'�� Certified Tester(print)�+2Vc�Y1 Certified Tester(si � ure Firm Phone#�}o'l-� �� IaQO Cert.TesterNo.1�d0141�31 Date * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS ��'��G **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: CIT OF COPPELL PWS I.D. #0570040 (Customer) � /�'ZQS MAILING ADDRESS: � CONTACT PERSON/PHONE: � �,� 9 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 IReduced Pressure Principle-Detector i�ble Check Valve ! I Double Check-Detectar �7PressureVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker :� Manufacturer �� Model Number 0�� /YI��_Size o� Located At ��►►DLI� �/�j �� Serial Number �� Is the assembly insta]]ed in accordance with manufacturer recommendations and/or local codes? 'L Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve ]st Check 2nd Check Held at � � psid Held at a,a- psid Opened at Opened at Held at Initial Test Closed Tightn Closed Tight v� psid psid psid Leaked'� Leakedf l Did not open .1 Did not open `I Leaked'i ' Repairs/ ,p��, �,�/�r Materials ,}�_f � „fn,,,k �` J� Used Tf (J�Cc .�a•� �C/� 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(/1/L/�/a175 �C-r'S sN: D 31 I a a q� Date Tested for Accuracy: �-� -a.blS Remarks: The above is certified to be true at the rime of testing. ' ' ' ' �sosl Firm Name D I�C��( Firm Address 1 Q,I( , (Xi(✓'I Certified Tester(print) �eU�Y1 Certified Tester(sig ure Firm Phone#q�"�,'33QI ' ��(/v Cert.Tester No. �t"��(0(93 ( Date �-oZ(o - �(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 IRRIGATION DOMESTIC FIRELINE V The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: 5�..�y ,�j� 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 [ iReduced Pressure Principle-Detectar ��-I Double Check Valve /�ouble Check-Detectar CPressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �/��,�/$ Model Number �,�0 /Q'�T�l� Size� Located At /(�G� �� Serial Number__�5�9/ $ 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��psid Held at 3'� psid Opened at Opened at Held at Initial Test Closed Tight�� Closed Tight � psid psid psid Leaked�! Leakedf.l Didnot open I I Did not open [' Leaked� 1 Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTightLl psid psid psid Test gauge used: Make/Model ��J��,�,I� 'T�a S` SN: O�o f'�� Date Tested for Accuracy: �-��-/s Remarks: The above is certified to be true at the time of testing. Firm Name � �,,,., ��.�y�� Firm Address f��. �q'� ��l.�pc, '7�"/6� Certified Tester(prEnt)�'p�,��y�ertified Tester(signature)�-� Firm Phone# ��"v�S?J--�28�''f Cert.Tester No.�PppO f�5�'J Date I2"j/�� * 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 Y The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recardkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: LOCATION OF SERVICE: The backflow prevention assembly detailed below has been ested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY C Reduced Pressure Principle �Reduced Pressure Principle-Detector �ouble Check Valve '��Double Check-Detector CPressureVacuumBreaker rSpill-Resistant Pressure Vacuum Breaker Manufacturer�f/�N3 Model Number �s0 �L Z Size� Located At /V. 1�t/s ��' Serial Number ,��70� �7 �--D Is the assembly installed in accordance with manufacturer recommendations and/or local codes? Reduced Pressure Princi le Assemb] Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �„ �psid Held at l�O psid Opened at Opened at Held at Initial Test Closed Tight� Closed Tight 1� psid psid psid Leaked I Leaked.1 Did not open I� Did not open f.' Leaked'i Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight❑ ClosedTight�_J psid psid psid Test gauge used: Make/Model !�v+�G�"�— 7t9� SN: t��a9'�`�P� Date Tested for Accuracy: �o�/a -�`� Remarks: The above is certified to be true at the time of testing. Firm Name�t�c.�+.. �� Firm Address ��_�T7�/� /� '�� 6� Certified Tester(print)��t,y,..c�e,� �Q,�,�Certified Tester(signature)�� Firm Phone# ��—SSo- �,Z a'�'1 Cert.Tester No. `$pa7� ��S� Date J Z.—//- 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