The URL can be used to link to this page

RPZ_2016_0613 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: � O U�1 �✓ �r' � 1 CONTACT PERSON/PHONE: � � � � � � - b`� LOCATION OF SERVICE: ' �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 I�educed Pressure Principle �Reduced Pressure Principle-Detector CiDoubleCheckValve ❑Double Check-Detector '7PressureVacuumBreaker I 'Spill-Resistant Pressure Vacuum Breaker Manufacturer l.�J Q`tT� Model Number �(�� Size ��Z Located At �r►'+ 4i$ Serial Number �-t3� �lo� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? VeS 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 �D psid Held at psid Opened at �. O Opened at Held at Initial Test Closed Tigh� Closed Tight I��! psid psid psid Leakedf ; Leaked�� Did not open [� Did not open ! � Leaked f:' Repairs/ Materials � Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight_7 ClosedTight'_=1 psid psid psid Test gauge used: Make/Model l pM�r'd P � "Z�� SN: 2� D�� Date Tested for Accuracy: ��/r��/S Remarks: The above is certified to be true at the time of testing. Firm Name ( ..-L�� Firm Address �� , Certified Tester(print) 19� �-• � Certified Tester(signature) � � Firm Phone# 2��-��o-�� O Cert.Tester No. Date � � �,3 �� * 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 LD. #0570040 (Customer) MAILING ADDRESS: �?�p ��y�,�p� C�r', CONTACT PERSON/PHONE: Lew i ` ,^�r _cE _ v LOCATION OF SERVICE: ��DD IYl OGK�'I��r ' j n 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 �i Double Check Valve C'Double Check-Detector �PressureVacuumBreaker I 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer w a-�J Model Number po '�j /� Z Size � ��Z�� Located At g��p�(,.L Serial Number � n[-�� jZ 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 lst Check 2nd Check Held at��psid Held at psid Opened at 3 Z Opened at Held at Initial Test Closed Tightl I Closed Tight ❑ psid psid psid Leakedf�1 Leaked� I Did not open ��1 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 Closed Tight i�] Closed Tight C� psid psid psid Test gauge used: Make/Model_�prv1 b►'uCt7 �0 � Z��j� SN: 2��lpO�j Date Tested for Accuracy: l�r j�'J/�� Remarks: The above is certified to be true at the time of testing. FirmNameC�,��e/I -1-5D FirmAddress � ��J (,V/rt P✓ �� (p � ) � � �� Certified Tester(signature) � Certified Tester r:nt Firm Phone# Z/� — `f�(O—��5f-� Cert.Tester No. Date �0 1� * 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 I.D. #0570040 (Customer) MAILING ADDRESS: O ` I � CONTACT PERSON/PHONE: � cnS 21 -�f — �l0 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 IReduced Pressure Principle-Detectar JDoubleCheckValve -1Double Check-Detector �PressureVacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker r� Manufacturer �U�, Model Number qoQ1 Size � ��Z Located At�� Fpt LL Serial Number �3�j�S7 1 Is the assembly installed in accordance with manufacturer recommendations andlor 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 Check Held at�psid Held at psid Opened at Z, Z Opened at Held at Initial Test Closed Tight� Closed Tight ��_I psid psid psid Leaked�J Leaked❑ Didnot open C`�_ Didnot open Cl Leaked�� I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight C1 Closed Tight Li psid psid psid Test gauge used: Make/Model �p Yv11�11!2 C C� �f'0 ' Za7�7� SN: z 5�l�C�d Date Tested for Accuracy: ��l��5 Remarks: The above is certified to be true at the time of testing. Firm Name�Qp�(.I �� Firm A ddress � J� W � � � . Certified Tester(pr:nt) �� 1r �� Certified Tester(signature) Firm Phone# ��T--[�L—��`f� Cert.Tester No. � Date .3 * 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