The URL can be used to link to this page

2016_0610 ,' i' 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: �ITY OF COPPELL PWS I.D. #0570040 (Customer) � �.. ��5� (.Z��"r MAiLING ADDRESS: =�'' ��'Z'°� �� CONTACT PERSON/PHONE: K--�� 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 operaring within acceptable parameters. TYPE OF ASSEMBLY I iR ced Pressure Principle I :Reduced Pressure Principle,Detector ouble Check Valve �Double Check-Detector 1PressureVacuumBreaker :JSpill-Resistant Pressure Vacuum Breaker �} �—�^ � rd Manufacturer '�i11�1( 17 Model Number ��/� r C�� Size �` Located At �� C�� W�� 1U� Serial Number � � `J � Is the assembly installed in accordance with manufacturer recommendations and/or loca codes? l� 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�p id Held at�psid ened at Opened at Held at Initial Test Closed Tight�� Closed Tight �� psid psid psid Leakedf�l Leaked'�7 Did not open I I Did not open [�] Leakedl��l Repairs/ Materials Used � Held at psid Held at psid °`� Test After Opened at Opened at Held at Repair ClosedTightL_; ClosedTight'� I psid psid psid � ;� "�c< `3 � � Test gauge used:Make/Model �v �'T �� SN: �� ''�►�� Date Tested for Accuracy: f� � �'- � ��8 � � Remarks: The above is certified to be true at the time of tesring. � Firm Name '1L�� ` �<<�� Firm Address �� •'�'�� ' 1�� (� j�Sd/g c�, � , �.,' y ( Certified Tester(print) ��'��"�� '��ertified Tester(signature) ��'�� r 'J� .� � Firm Phone# �� 7�� Cert.Tester No. �� Date � lb � * 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 1/ 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 1.D. # 0570040 (Customer) �� MAILING ADDRESS: �v S fi'oC�S�Ur� g� Co �� Sv/ CONTACT PERSON/PHONE: J4�-Rwla L'a.fe.� (oPr,? - a7a t/-G'�5� LOCATION OF SERVICE: SD S fi�ou�r�ir� S'f 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 �lReduced Pressure Principle-Detector IDoubleCheckValve : 1Double Check-Detector 7PressureVacuumBreaker 7Spi11-Resistant Pressure Vacuum Breaker l ',�� Manufacturer ��Y� Model Number LFL'o��•t a Q�" Size � Located At ��5 p(� �� . S�e �b�i� Serial Number � SSp�c� Is the assembly installed in 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 Held at�psid Held at�psid Opened at -�� Opened at Held at initialTest ClosedTightl� ClosedTight I'-1� psid psid psid �''�� Leaked f 1 Leaked'� I Did not open I 7 Did not open I I 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�,rnbrat� �b -�OD~ TI�S SN: ��a o`�a�Co Date Tested for Accuracy: ��ay�/S Remarks: The above is certified to be true at the time of testing. FirmName •�� N�flf D�y�at�f�iki��ky Firm Address lyl� �� C�� l�cr„ �j �Su/3 r � Certified Tester(print) �.5,/�el �um�e(� Certified Tester(signature�_,��=�r�l • Firm Phone# i�lf'-al��(��(l5 Cert.Tester No. /��Oo/(v(�� Date � �� (o * 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