The URL can be used to link to this page

2016_1228 ,�-- _ 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 I.D. # 0570040 (Customer) �/ � r- O I MAILING ADDRESS: L-�4�.� CONTACT PERSON/PHONE: 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 ❑Reduced Pressure Principle �7Reduced Pressure Principle-Detector i 1DoubleCheckValve �4Double Check-Detector ❑PressureVacuumBreaker '�Spill-Resistant Pressure Vacuum Breaker Manufacturer �t'�� Model Number �� 1l�.��'C Size ��1 Located At V�t� �� 1`tv�'l'1` �� Serial Number W«� 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 `1'�`V Held at psid Held at psid Opened at Opened at Held at Initial Test Closed Tightf '� Closed Tight ❑ psid psid psid Leakecl'�, Leaked� Did not open f� Did not open !� Leaked� Repairs/ �� •-�y�� ,�yn �.A,s ., . ` �� Materials �y� r—��' r�w� Used .�.� • ��I`��J—['�� / Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight i� Closed Tight❑ psid psid psid Test gauge used:Make/Model VV �L{�i�5 �'� SN: �� 1 '�� Date Tested for Accuracy: «` � I ��r, Remarks: �~� The above is certified to be true at the time of testing. � G �^ Firm Name C��J G l�i � V�'U�Firm Address � � Q�fl �� • Certified Tester(print)� l' �Q- Certified Tester(signature) Firm Phone# �/��T�0 '��-- Cert.TesterNo. kJrU�V-tb� Date � *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 I.D. #0570040 (Customer) /�, � — �, MAILING ADDRESS: d`l0 CONTACT PERSON/PHONE: � - � 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 C;Reduced Pressure Principle iReduced Pressure Principle-Detector �DoubleCheckValve C'.Double Check-Detector �7PressureVacuumBreaker !:iSpill-Resistant Pressure Vacuum Breaker 1 �� Manufacturer �1'�11t5 Model Number ��'�� Size � LC Located At � ��T I`tVi'�l�- �V�i Serial Number ��D 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 Cl�osed Tight� Closed Tight �:I psid psid psid Leaked� Leaked� Did not open ,. Did not open l Leakedrl Repairs/ (��n� �Q� �� Materials F�✓1 �v,� Used Held at 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 Y�l V�-�� 1�t SN:�l� —�� Date Tested for Accuracy: �a- �o Remarks: The above is certified to be true at the time of testing. FirmNam�� WUM� Firm Address Iv"�J� �� • � Certified Tester(print) l�i(/�� Certified Tester(signatur Firm Phone# �T �' "1 B h Cert.Tester No. � 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