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2016_0516 i � IRRfGATlON ' ❑OMESTIC FIRELINE �€ � The fc�llc�wing form must be c�mpletet� fc�r each assembly>tested:�A �i�ned ancl dated ori�in�l � must t�e submitted to the public w�te�-supplier far recordkeepin�pu�pose�: ; . ; BACK�'LO�v4 PRFVENTION A�SEI�ZSLY TEST AND MAINTE�r�ANCE REPORT , i I �� �� � �� NAM�OF PWS: CIT`Y OF COPPELI, PWS I_D. #Q570040 � � (Customer) �� � � < � �a -a � � � � MAILIN�G ADDRESS: '�;��,t-� �� �� . , +.. �'• v,� �� � �`�� �� _'��� � �-r�� � �� � '=� �t��:�� CONTACT P�I�SC)N'PH�I�TE: . �� i ��.,OCATION OF�SERVIC�: ,� �� �:��� �� � ��.���� ,�.,.�;� ;��`��3._� � � � � _ E � The bac�Cil�w pr�vention assetnbl�,detailed bel�w has��'been tested�i�d m<�intait�ed as requir�d by � �� �� � coinmissi�i�re��lations an�i is certifted to�be qpet�atin��vithiit acceptpbl�paramc�ers_ �� ���� � � � � � � i T�'PE UF AS3EMBLY � � � � � ' �Redtzced Pressure Principle � � ;R�ciuced�Pressuxe Principle-17cfector � � I�oubieCheckValve ^fi�ouble Check-D�tector IF'ressurcVacuu�nBreaker S�ill-I�esistant Pressiu-e Vactium Brea�:�r Manufact�n-er =;�.4 :; a; , �, Model Number� :'�j --� #d� �`�'�"'.�'� Size '� , � �� Located ,At`���, :,-- ( � i`,,,.� ;µ, � c .�t:-,.,�,� c�� �*•,��� 7 Seri��i Number � � �� .�'°��' '� ��� � � � Is t11c assembly i��stallc;d i�a accordance with maiiufact�ir-er reeatr�tnendations andfor laca] codes?�,�� � � � Re�iuced Pa•essure Princi le Assembl Pr�sst�re Vaeuum Breaker � � � � Double Check Vahre Asseu�l�ly ` � Relief Ualve Air Inlet �heck Valve 1 st Check 2nd Check ' Halci at� �'�-}�sid �Held at""`? j"�sid Opened at '��, Opei�ed at l-ieldlat � Init�al Test Closed Tig�ht~fi"` Cl�sed'Tight �°�"` psid '_ � psicl psid � Leaked 1 ` Lcaked Did not open Did nc>t open Lea�ed' ` Repairs/ ATater'rals ' Used ' 1-leld at psic� HeIcl at psid Test After O�p�neci at �� Opeztud at Held�t Re}�air C'losed Tight � Closed Ti�k�t � p�ici psid psid i � ; Test gaugc used:Make,�!tociel 4�.�-',?,. ..�x� ,'�t t�� _ SN: ' �' � ` r`� '7 ,; Date TestEd for Accuracy' � + �; � 4� � ' Remarks. � � � � �s � � The abov��is certified to be tnle_at the tin�e�of testing_ � � Fint�Name`��`��'`;"µ�t� '� �,�;� �� �,~,� �; � � ` � r:"• , � � , i, `. - g �` . � � � �..� '. ,: , ; , .��,. -��-� Firm Ac�dress ° t :� • � ���� ' ,� � � � � .� ,� � � � Ce�-titied Tester(Pa'nt) ���� 4_ ��`_`� ���.��! ��',�=Ccriifiec�TeStei-�{signaiure) �� �'��: �"�� r� �r ,� �,?„�,��-� � Firn� FI�ot3e# -`�#�� `�� i �.3�g f��� � Cett.Teste��No � '`�" �� : � I)ate �� .� �. _ �{;, � �` TEST RF�dRnS�UST BE KEPT FOR�T LEAST'Tf iRE�YE:ARS � � **USE ONLY MANUE�ACTUR�R"S R�F'1.ACEML�VT PARTS lUhitc-City Co�y Ycl1c��--Cuscp�ncr Copy Pink-Tester's Copy � ; IRRIGATION DOMESTIC - ' FIRELINE �� Thc�following farrn iltiust bc�co�npieteci for �ea�:li assembly� te�ted. A ,signed�and dated origin;�tl � must be submitted ko fhe pt�biic tivater suppiier for r-ecorclkeepiti�pur�oses: � gACKFLOW PREVENTIOI�A;�SE111BLY`CEST Ai�'D l�'1AfhrTFNANCE REPORT � NAME OF Ft�S: C1TY O�' CpF'PELL PWS I.U. #OS7Q040 (Gustomer} � Iv1A1LIi�ICi ADI7'RESS:���..�--t a�-���� ��;,,> �- �>'�r�....��,�,t �,,, �� � S�-�.�� �x.>�� �#a«�,, � � � � COI�'TACT PERSONI�HCINE: i � � � ---..._ LOGATIC)�! O�'S�RVICE: �, � n: �" � �,. � � �> µr .E )���� ,��. , i � � Thc back{low prevelitioza�as�embly detailed belo�w 11as been tested�rid mairrtai�ed as rec�uirEd by � aointnission re�ulat�iuns and is certi�f ed to�be operatin�K�it}ti»acc�piable paraliielers:����� ' � "X`l`PF,OF ASSEMBl,Y -iReduced Pressure Principl� Reduc�c�k'res'sure Pz-inciple-DetectQr 'Doul�leCheckValve �ot�bl�Ciieck-Dekector �-!PressureVacuu�nBreaker ��, �Spill-Resistant Pressure Vacuum Brea�cr � Niarxufacturer !.,�._1 . ; �; � � IViodcl 1`�unauer '"� '''�»-_° �- ;� Size ��`r , Locatcd At�,t�.�x ti a ��a 1 e. �.,,,,. _ ;, r�,,>,. � ~-� Serial Nui�iUct _ti<=� � �; =,� s �: � Ts lhe assetnbly installed�n acc+�rdance witl�n�an�uf�cturer reec�mmendations and/or]ocal codes? °�� r� � T � R�ducc�Fcessure Princi �e�Assembl '�� � Presst�re Vac�ium Bre�ker Double Check Valve Assembly ' � Relie€V'alve ' Arr Ltlet Check Vnlve lsi Check 2nd Check I�eld at��''- ��psid �I��ld at � ,�.psiel i�p�ned 2t C)��ei�cd at'�� � Heid�at �nitiulTest ClosedTi�ht� CloseciTight ��'' psid �sTd �,�d � � Leaked Leaked I � I]id i�ot c�pett �'� I)id not open �! Leakcd� �� Repairs/ ; b�aterial5 Used Helc]at psid }�eld at . }�sic� Test After �� tJpened�! Opened�t � HCtd}it n R��air CloscdTight ( ClosedTigl�t" �� p�Yc� � psid psi� I � � , E ; � � '` �}`'� '"r��-, Test�au�eused�MakelModel ��s� , � S�I: �� ` � ��i '� � ' � Date Tested for Accuracy: i�. + �� j � . Remai-ks: ! — ; The abot�c is eerfified t�be tt-ue��at the time of testing.�' � � � � � � � � �� , � � �� ������ � $ Firn�l�Iatne ��i`,��`,:{� ; fr7����,�..��°r ',�"'r:�_t Firrr� Adtiress �e;'f, ' ."` # g �, � �; ' , . ,'x �s � ;e f a� ' � �' _ .� � " � � .-,, �- " � I � Ccrtified�Cester(��'ant} i��� �.� 7�=�� ���i���1����'�_.Certifiied Tcsiei;{si�natu�e) �'�� �i��, ���'� ,, ,..e '��;,��=� Firm Phonc# �5�t 'ff � 'd ,' ��j Gert.Tester No. �p,����''��w� Date �' ,� �, _ 1�1 *TEST RECORDS MUST 13E,KEPT FQR AT LEAST T�IREE Y�t\RS **USE ONI.Y MAl'�flJFt�CTURER'S REPI,ACEMENT PARTS I �'hite-City C;o��y�'�� Yellow��ustorner Capy � Pink-T�ster�s Cop� ��� �� � � �� IRRIGATION QOMESTIC � FIRELINE' �� ' The fotic�wing���form �nust bc cc�mpletec� fo�- each assemb[y�tcst�d. A signed and datec3 origin�l � � n�ust be subinitteci to tlle ptiblrc��ater supplier for recorakee��ing pi�rposes: i , ; BACKFL0I�V PREVENTI(}N ASSE1.Vtl3LY TEST AIYD 17AINTEN,�NCE REPOR"T ' � : NAME OF PWS; CITY OF COPPELL PWS I_L�. #(157q040 ; � (Customer) ; MAILING t�DDRESS: �� �,�: ��� � � _' �-�..,x�_L�,���� � .,� � _,. �-� � > � � � ---� °^� .t�'`",/ '�. �` ��+.-�, CONTAC`I`P�RSON,"PHONE: ' ' ; L,QCAT'i�N OF SER�ICE; (:� -;3:� e, ��'", ,�� � �, _� �_�� � � 'I'he Gackflow pre�ention asscn�b]y detailetl belpw 11as been testcd and in�intainccl as r�;quircd by � � � con�missaon rcgu[ati�ns and is certitied to be c�perating within accepi't�blepar�unekcrs. � � �� � TYPF OF`ASSEME3LY -Redueed Pi-essur•e Principle � � Recluccd Pres�ure f'rinciple-Detectof- ` �I�oTlbleCl�eckValve � � � �auble Ct�eck-Detector� � `iPresst�re�'acuuinE3resk�r S�ill-Resistanr Pressure Vacuum Break�r Manufaeturer_ �_�..� ; ���'� �� ��-x� �Model Nun�ber °y `:�'��_. `��'�`�"� � '°�. Size �`'; � � ' �� -:�" '` �" �.�����„ . _ � . .� � � t � Located At � �, ' ' , ` � _ �,+..-.� �, .� �,, � 5�ria1 I�Tuinber `� 4�;�=-� ;��t�� i �— i Is thu as�ei��Uly installed in at;cordanc�s�-ith manufacturer r�commendations�nt�/or local codes? �_a -t: � �� _ Re�iuced Pressure Pi•'rnci 1c Assemblv Pressure Vacuurn Breaker � � � Doable t>heck Valve Assembly ' , � : RelieFUalve Air inlet ChEck Valve 1 st Check 2nd Check , ; Held at� � psid H�ld a�� `"� psid C3gened at t7pc�tcd at Held iat initial T'est Closed Tigtiti �r'� Clasec�Tight ..�" psi�{ �,sid psid i, � � Leakeci' ; Leaked_� Did not o��en ' I�ici not open -' L4ak;�d�_ 1 Repairs/ ` . Materials ' Used ' Helel at psid �lcld at ps7cf �I'est After � Ope��ed at__ Capcued at �� F(�Id�t Repair C(osed fight � ('losed Tight � ps�a � pSi�{ � psid � , ; ; � ��� Test gaugc used:Make,'Model '�'��� Yr`` '��'� SN. ���s���' ,' �' ��' Qat� Tested for Accuracy: � - +�� � ,.� � �� � Remarks: , � 1 The above is certified to be true at the time af testing_ � Firtt►Name_ ��4�i`�j �'r',�6 � s�,r � F ���a.�[ � Finn Address �,'��_"�`'� `� '"�$ '�� �' � � . ' — �; �� f� ' Certified Tester rint) ° - � � � ��� " •��# ��� � � �P �- �Y�ertr�i�d Te.SteF(signatur�) �� � �� ��'� =;+ � �� � � ,�, .. ,. ., � � Firm Phone# _;f��' _�° ; ! �� � ` Cert.Tester I�� ` r'� ,r - Llate `"�_ > � � y :,.. *TEST R�CORDS MUST BE KEPT FOR AT LEAST THREE YEhRS ' �*USF,ONLY MANURACTURER'S REPLACEMENT AARTS ' Whife-C;ity CopY Yell�w--Customer Capy ' Pi�tic-Testet-'s C;opy , g � � IRRIGkTIaN I dOMESTIC FfRELINE� �"`��� i � The follov�-ing rorm t�usi be completed �or each as�ernbly�� tested. � ,si��ed anc� dated origina] � must be submitted#a the public waker supplier for recordkceping ptt�-poses:� � � � BACKFLOW PRE'4'FNTIOlti ASSENIBLY TEST A1�D�1AINTENANCE REPORT NAME OF PWS: CIT'ST OF C'•OPP.ELL P��S I.D. �0570040 (Gustomer) � ' MAIL[N�GADDR�SS:�'��;� �. �-���, u� ��� ��', «,�.�,����t � #:� �� `� i � �� .�,��-� !�?:._�,�� CONT�ICT PF.RSON/PHON�: ' L�CATION OF S�RVICE: �:�"°�.1 ���� � � �.�� � � >''���.. �- � ��'�. � I Tlie backf7atv}�reventron assembly c�etailetl belotie has been tested and maintair�ed as rcqaire�l b_y � comznissioti regulatians and is c�rtifiec�to be c�peratin�within acGeptable para�t�etet�s. � � � � �� � TYPE:OF ASSE�'TBLY ' � �"R�duced PresstEre Princi�le��, � �� Itediaeed Pressure Frinciplc-I�etectoi ; �Double Checlt Valve �quble Gheek-Detector ` �Pressurc Vacuun�E3reaker Spill-Resistank Pressure Vacuum Bt�eal<er IVianufactucer �-`� < r i� � � �. A�Iode1 Number �."=�` ,;� '�f .�: � '`;� Sizc t��"o= � , � Located At�Jt. ., � �� �..� �- �,; `;. ����+s�, Seri1l Nurn6er �w�'1`.� j'�,, c.� � T�1 ' Is t11�assembly installed'in accoi�dance��ith manufaeturer recamm�ndations and�`or lo�;al codes?'�.,,< � � — Re�lucecl Pressure Prinei� 1�:Asseznbl � ��� � � Pressti�rc Vacuum}3re�ker Dc�uble Chec[c Valve Asseii�bly t � � �� ReliEf�'alvc � ��� Air Inlet C`heck Valv� 1 st Check 2nci Check � Held at '� psid� Helcl at `""� psid ��pened at '�� ��� Qpet�cd 1t Hel�aC Initial Test Clascd Ti ht Closed Ti�hi ' psid ' psi�i p�id` � � � Leaked� Leaked�� I�id�ltot<�pen ��� I�7id iiot open . � Leal�ed l��� � Repairs/ �' k .,�:.•' , ,�� � � .�r„- ..� < :% ' Maleaiais � � � � � � Useti �,��.:' �' ;:�,� �«.- � � ��� ��� Hel�1 al�.�.,.- �� psid ��Held at��psid '��� � Test After �� Opencd at CC�pci�c�l at Heldlat � �' Repair � C`t�seci TigF�t-�'� ClQsed Tight -�°'' �siti psici � pyid � � ` � Test gaugz used:Make/Model ��'��f` -� �„� ��' =t� SN:_ ' `�r� .<•`�� � � Uate TestedfarAccuracyc � _:„'�� � �. 3 , M Remarks: The above is cerlified to be true at the tr►n�c�Ftesting: � , � , r � � e,�� � , � "- � � � . � � �F11-[11N3171� f �r la e 4 � (,r"�?f FIT71t f�CjC�f'eSS ��& � �'r^ :i� �, �`a�`�t`� }` t '�'� � � _ _, ,, $s �� � '�'s c.r�k; `l�€.�t�6� .. � � �i Certified"['ester(pr.nt) ` i �* �� �Ceetified T�stea�(signaY�ire) � � �� �r C'���.��-�.. ,„: �a� .�:�`' ' � Firrn Pt��ne# {;�4�d `�'_:� -�� �`'?� � Ce��t.Tester No. ° ° ��`� I7atc '`�.� f �,,, � !`� *TEST REC�RDS MU�T BF KEPT FOIt AT L�;AST THR1�E Y�ARS ' *'� USE ONLY MANUFACTURER'S REPLAGEMEIti�T PARTS ' i � Whire-C:ity Go�y Yellou�-t"ustc�i��cr Cc�py ` Pink Tes�er's Copy � � I