Loading...
2016_0114 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 far recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: �fir�,��,� 13a —rn u�Y1 �2Y��'' �� CONTACT PERSON/PHONE: LOCATION OF SERVICE: , Qml� 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 ❑DoubleCheckValve ,KlDouble Check-Detector ��PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer��S Model Number�R� �� Size�_ Located At 1 Y1 J � ��1'�YA,YIf�CC. Serial Number �� �02�0� 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 psid Opened at Opened at Held at Initial Test Closed Tight[�] Closed Tight ❑ psid psid psid Leaked[�1 Leaked❑ Did not open ❑ Did not open ❑ Leaked[1 Repairs/ � � S��.."�- t� � �0�4' �a �^�` � �� � � �a 1/(�c./ �� �'�P-e`\ Materials Used �'�O�v-� �a CV'�" �„r.,u� bj SS �S G���� ��n��� $�� —��,(�OC�m � 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 Vv i `�^�� � � SN: ��/�7 v S 7� Date Tested for Accuracy: a ' ' �.� �� �� , b �t bL P�¢-h Remarks: r� !�-� � i� l�e. �' ^e � �,,� ,' - � . The above is certified to be true at the time of testing. .�.���-a pt,,,,,i� ✓�-(��7'. / Firm Name�'� '!rc, 'a' �n �L j��Firm Address�+�.�o��b��i�i(,va rf-1,,�7(,/�� Certified Tester(pr�nt) .✓��`h /�'� Certified Tester(signature) ���.�i-'" � Firm Phone#�I%���� ' S� 7 � Cert.Tester No.f3 PUo/7 3�� Date 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 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 for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. # 0570040 (Customer) MAILING ADDRESS: � �� � =�f•!� (3 0 11Jn �✓C.� CONTACT PERSON/PHONE: 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 "'�DoubleCheckValve ❑Double Check-Detector C]PressureVacuumBreaker ❑Spill-Resistant Pressure Vacuum Breaker Manufacturer INQ�S Model Number 0��m � Size 3� Located At� �/��0 P Y1'}1�D1,�'1C�, Serial Number �p B� 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 psid Opened at Opened at Held at Initial Test Closed Tight❑ Closed Tight ❑ psid psid psid Leakedn Leaked❑ Did not open '��l Did not open ❑ Leaked❑ Repairs/ 7 (�'� �9�- G�--tJ` � a�.� -}-o��- � -(�� ;.r.�y1, Materials ��SS��� C�L�— R2plaCe rne usea b� %I r,�cn v�� ��-c.✓ 'r� �f s;� a F b ss (o -��.-,,.�. ,,�� � Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight[_] Closed Tight-1 psid psid psid Test gauge used:Make/Model+iJ� ��G�S ��C; i SN: D�o � �7� � � � Date Tested for Accuracy: �� � 3 " /5 Remarks: The above is certified to be true at the time of testing. FirmName I'/�1- �r� v'- Vo��--�s-f%� ��s�`��'irm Addres��� ;�o�c '�1.�yo��'�'l,`��`�.�.� ����! �o ,� Certified Tester(prnt � .� ��-� o- —�Certified Tester(signature) Firm Phone# � [7 l�3a�S S % % Cert.Tester No.,�,�0015��-> Date r * 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