The URL can be used to link to this page

2016_0112 IRRiGATION�_ ' DOMESTIC FIRELINE The following form must be completed for each assembly tested. A signcd and dated original must be subrnitted to the public water supplier for recordkeeping purposes: � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF �'OPPELL PWS 1.D. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE; - LOCATION OF SERVICE: t9 The backflow prevention assembly detailed below has been tested and m in ained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY � � �educed Pressure Principle ' 'Reduced Pressure Principle-Detector J�Double Check V alve -��Double Check-Detectar PressureVacuumBreaker Spill-Resistant Pressure Vacuurn Breaker � `[�- �� j �( Manufacturer � � Model Number Size Located At � ,lt�'� Serial Nwnber�� ls the assembly installed � accordance with manufacturer recommendations andlor local codes`? Reduced Pressure Princi le Assernbl Pressure Vacuurn Breaker Double Check Valve Assembly Relief Valve Air lnlet Check Valve 1 st Check 2nd Check ��i Held at��psid Held at� si Opened a[ Opei�ed at Held at nftial Test Closed Tigh � ! Closed Ti�ht ps�d psid psid Leaked � Leaked Did not op�n Did not open Leaked Repairs/ Materials Used Held at psid Held at psid Test After� Opened at Opened at Held ai � Repair ClosedTight__! ClosedTight psid psid psid Test gauge used: Make/Model � �6T��u SN: �3I��T Date Tested for Accuracy: 5-1 �� Remarks: The above is certified to be true at the time of testii�g. Firm Name � �� Firm Address �lL� YUi�� i�f')��{�'l+./� Certified Tester(pr;nt) G�� l9Dn'C� ertified Tester(signature) Firm Phone�#`'/ �ol'�� Cert.Tester No. � � �� Date � � *TEST RECORDS MUST BE I�EPT 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: CONTACT PERSON/PHONE: LOCATION OF SERVICE: �� , J.f1/)�� [SCt 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 1Reduced Pressure Principle-Detector �ouble Check Valve C'Double Check-Detector I 'PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker y^ I li Manufacturer t-P� Model Number g J� Size Located At I Tf Serial Number r/� �,�� Is the assembly installed n accordance with manufacturer recommendations and/ar 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 PaSsQ� Held at��psid Held at Z- ` � psid Opened at Opened at Held at Initial Test � Closed Tigh� Closed Tight� psid psid psid Leaked�7 LeakedCl Did not open �.; Did not open ' I Leakedl I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight��1 Closed Tight[�:l psid psid psid Test gauge used:Make/Model�Qg(�� G�DDTK�C( sN: D3/ob C�(�� Date Tested for Accuracy: ,�� /S Remarks: The above is certified to be true at the time of testing. FirmName '��f/��j�y''/d�l//d Firm Address��f/��G/��Y�l�//Jc�S f/��-�-' Certified Tester(print) v' � d � Certified Tester(signature) Firm Phone# �7�- ��o�-�Q�� Cert.Tester No.,�/r��D �� 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