The URL can be used to link to this page

2016_0821 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 LD. # 0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: `3� 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 ' duced Pressure Principle I IReduced Pressure Principle-Detector � ouble Check Valve [ 'Double Check-Detector ' 'Pressure Vacuum Breaker I I Spill-Resistant Pressure Vacuum Breaker Manufacturer��'�� Model Number �d7 r', �Size `�1'� ! Located At �f� V(�U��PJS� �_�1[��Serial Number a �a�� q 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 T� ti 1 Closed Ti t �1 psid psid psid Leaked�� Leakedl� Did not open I � Did not open [1 Leaked�� I Repairs/ �l U S� � 1 ►'�e �1 � � ��C�'S Materials /� r t �•� Used l.�l�� "�' ( �' �' C Y1C��5 Held at_j�psid Held at��psid Test After / Opened at Opened at Held at Repair Closed Tight-_ Closed Tight I^1' psid psid psid Test gauge used: Make/Model �i�iC j��71.�j SN:�$ (��,��9 Date Tested for Accuracy: - Remarks: � ��S"�"�}( ' �(��S �►-��'2S'��C-�CS The above is certified to be true at the time of testing. Firm Name�iS �'FI��(�("�irm Address��,�� (' )`SV��'��X��i� T Certified Tester(print)s��B�ertified Tester(signature) � Firm Phone# ��-�P�� Cert.Tester No.�P(��d� Date ~�� V�' ��r� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS �"�� -0 **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 ariginal must be submitted to the public water supplier for recordkeeping purposes: BACKFLOW PREVENTlON ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) MAILING ADDRESS: CONTACT PERSON/PHONE: YY�O A c.� �- ��R 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 ' i Reduced Pressure Principle I uced Pressure Principle-Detector ��7DoubleCheckValve �� ouble Check-Detector �PressurcVacuumBreaker ��Spill-Resistant Pressure Vacuum Breaker Manufacturer__��}'�'CS Model Number7J��DR-(7t� Size�� Located At,� �!(�(„L��S� �'/� Serial Number �L o�$'�� Is the assembly installed in accordance with manufacturer recommendations andlor 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 Ti tl I Closed Ti t �� I psid psid psid Leaked�� Leakedl� Did not open f.'� Did not open I '� Leaked� I Repairs/ � IUcJh �'(V/L'e � i e. A�F ,s Materials �� J ,�, t � � ��s Used �� Held at , psid Held at psid Test After � � Opened at Opened at Held at Repair ClosedTight� ClosedTight[_� psid psid psid Test gauge used: Make/Mode1�F��%/2� / 1�j-( 'r] SN: ��(0�9 Date Tested for Accuracy: � -� �,�� Remarks: The above is certified to be true at the time of testing. Firm Name�i�� flc� K/?.�Firm Address��.�� f��,J j j��'�� Certified Tester(print) Certified Tester(signature) � Firm Phone# �L��-�� Cert.Tester No.��7d'r" Date �� r j'" � � �(��-� �}�'(`�!''h� r�� * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS $ ��r�- �� **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy