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2016_1102 (2)
, � � . _ ,.__. . ___. ___.�_ . . _,._. . _.� _ i � ; IRRIGATION DOMESTiC FIftEUNE Thc: following fo�m must be coinpleted for each assembly test�d. A signed ancl dated oi•iginal musT be submitted to the public wat�r supplier for rec�rdkeepin�purposes: SACKFLOW PREV�NTIOIV ASSEIViBLY TEST;A;ND MAI`tiTENANCE REPORT NAME OF PWS: GITY OF COPPELL PtiVS I.a. �OS7Q04Q {Cust�mer) � ' � VIAILING ADDRESS: ' � �� � � � >�� � COIvT�.GT PERSON/PHC?NE: , ; � ��' V��,- �` � ;r.,�� ,; LOCpTIC?N O�SERVICE: � , P�'�,-. <:; The Uackflow prevention assembly detaited bel�w has been t�sted af7.tt iz�aintainecl as required by co�tunission�•egviarions and i�certified to be operating�vithin�ccepta�le�arainet�rs. TYPE QF AS�EYIBG�' Reduced Pressure Principle � Reduced Pressure Principle-Detector '.D�atibleCheckValve Dauble Check-Detector �:Pressur�VacuumBreaker -<Spill-ResistantPressure VacuumBreaker �anufachirer �"�' � �� � �`�� �'�'� �Vlodel NEtmber� �` Size � � Locatecl At t `` ' ; Serial!Nun�bei � �+ ' .� is tlhe assembiy installed in accordance with manufacturer��ecominendations and/or lacal codes? '. � ; Reduced Pressure Princi le.4ssembli� Pressure Vacuum Breaker Double Clieck Vaive Asseinbly P�eliefV"�ilve Air Inle,� Check Vat�E � i st Check 2iid Check ��..�` , '�� ` �t '::' ,� . `' Held a�;,� � psid He[d at�.�� psid Opei�ed at`_� O�::acd'al.,,__ � F(�:ld,at�� � ,�—.�.. � �. Initia!Test Closed Tight::,,... Clased T�ght =�w psid! '�'° ps�d��' '` _�.��.= psid ,`'''� � � � _,_'` '.. :- Leakecl�: Leakedi. Did r�h�pe�i: I���not open ` ' 'L�eFrlced Repairs! , ` Niat�rials Us�:d Held at psid Held at psici ; � Test After Qpei�ed at�� Upened ac Heid at Repair Closed Tight_�i Closed Ti?ht�; psid� �sid psid � . ; _ Test gauge used:ivtakclMode( � "� `r � ~ SN: f - '`' � . I Date "I'ested for Accuracy: {' � fi� Y'� , Remarks: { — � The abuve is certified to be truec at the time of tzsting. Firm Name e '�} .�-e.£-��9t; .,+� s ��; -��s r �ICITI h1(Idl'ESS; � >"`'� .,��'�'� � -. '�- ` , �: Certified TesCer(prinr) ���r � �`: ; v��1,��-°+�,� Certifiec�Tester;�signat��re) � ��"'� � �� � � t � �.�. .' ,� ; _� ""' �'' Firm I'�ione# �� � Cert.Tester N�. ��� � Date , f �.'; ,��;x< � � .� *TEST RECORDS MUST BE:KGPT FOR AT LEAST�CHRE:�:YEARS *'�USE OI��LY MAI�tUFACTURER'S REPLACEMENT PAR1'S � f � White-City Copy Yellov��-Cvstonier Co�� Pink-Tester's Copy � � , �,