The URL can be used to link to this page

2017_0630 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) . 1 / MAILING ADDRESS: ��03 �✓�'u 1 �i�i' � �' � �- CONTACT PERSON/PHONE: � ' � 2/`�- � `E� LOCATION OF SERVICE: � � r C The backflow prevention assembly detailed below has been tes d and maintained as required by commission regulations and is certified to be operating within acceptable para�neters. TYPE OF ASSEMBLY �educed Pressure Principle �:-1Red�iced Pressure Principle-Detector � IDoubleCheckValve ' ",Double Check-Detector f I Pressur�Vacuum Breaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer �Q'�-C� Model Number�/�QQ� �t� Size ��Z- Located At �� BI'� Serial Number ��3 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? C,5 _ Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Re(ief Valve Air Inlet Check Valve � l st Check 2nd Check Held at °�_�psid Held at psid Opened at� Opened at Held at Initial Test Closed Tighti 1� Closed Tight �1 psid psid psid Leakedl I Leakedl I Did not open � Did not open ' Leaked � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' I Closed Tight I psid psid psid Test gauge used: Make/Model �1►'I U/�cf.p ��'"�a� / � SN: ��U�� Date Tested for Accuracy: 9��l� �� Remarks: The above is certified to be true at the time of testing. � � � � G// Firm Name � d� -L- Firm Address ��0� G�l • � � � Certified Tester(pr�nt) � � Certified Tester(signature) � Firm Phone# �`T^`C ( rP��7� �� 7 Cert.Tester No. Date *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REFLACEMENT 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 recordlceeping purposes: � BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) ` � � el! �� MAILING ADDRESS: 13p3 Wran. f3' �-+'r� �D � CONTACT PERSON/PHONE: L-Ou r S Zf - � G - �G LOCATION OF SERVICE: � r The backflow prevention assembly detailed below has been ested and maintained as required by conmlission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY �educed Pressure Principle ' �Red�iced Pressure Principle-Detector � IDoubleCheckValve ",Double Check-Detector ! IPressurcVacuumBreaker iSpill-Resistant Pressure Vacuum Breaker , 1 r� Manufacturer 4Jt`J I/'15 Model Number �� -- Size (/Z Located At 1��lr1G'� ��11C�S5i Ofl Serial Number � �� 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 .3•�o Opened at Held at Initial Test Closed Tight� Closed Tight �1 psid psid psid I Leakedl I Leaked' I Did not open I Did not open ! Leaked ', Repairs/ I Materials Used Held at psid Held at psid i Test After Opened at Opened at Held at Repair Closed Tight' I Closed Tight t psid psid psid I Test =au e used: Make/Model�Lv �D- Zo� 1 `- sN: �s goae� j b g Date Tested for A.ccuracy: �} I�/��o Remarks: I I The above is certified to be true at the time of testing. j Firm Name �� .�� Firm Address � � l� i � �"` � j \ ` . Certified Tester(pr�nr) �U�� (� Certified Tester(signature) � � /�� ¢ � �� - Firm Phone# �� -�Q� �� Cert.Tester No. �1J10��U Date � *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I, **USE ONLY MANUFACTURER'S REFLACEMENT PARTS � White-City Copy Yellow-Customer Copy Pink-Tester's Copy j 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: i 3� � � � � � CONTACT PERSON/PHONE: ` ' Zi'f- ��1� -�b�U LOCATION OFSERVICE: I rLwa 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 '-IRed�iced Pressure Principle-Detector � IDoubleCheckValve :Double Check-Detector I IPressurcVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker Manufacturer�-t'i3 Model Number /� I Size 3�/ Located At I-�1`e�2Y1(%� �t�� 1��St'►� Y'� Serial Number ( 1'P'T�(v Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �eSS 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 7 5 psid Held at psid Opened at 3.� Opened at Held at Initial Test Closed Tightij4 Closed Tight � i psid psid psid I Leakedl I Leakedl i Did not open , ' Did not open ! Leaked I Repairs/ Materials Used � Held at psid Held at psid � Test After Opened at Opened at Held at j Repair Closed Tight' I Closed Tight', ! psid psid psid I I I Test gauge used: Make/Model M bf�o 40`�� IL SN: Z�80C� i Date Tested for Accuracy: ��g'�Co I Remarks: I The above is certified to be true at the time of testing. � Firm Name ( �S� Firm Address '3�3 W� $ ��t� i �� i � , , I Certit7ed Tester(prznt) �_ �� 1 Certified Tester(signature) � Firm Phone# �.r�`��v ' o�`rd �(�I��Date 30 �7 Cert.Tester No. j * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REFLACEMENT PARTS i White-City Copy Yellow-Customer Copy Pink-Tester's Copy i IRRIGATION DOMESTIC � FIRELlNE The following form must be completed for each assembly tested. A signed and clated 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: (�� ►'�►'�4�� C;✓ �P�i��-� CONTACT PERSON/PHONE: Lc��.cis ic�5 �'��- 4 I�"�`�� LOCATION OF SERVICE: ��S� l�� i�arkw��-+ - 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 �IReduced Pressure Principle iReduced Pressure Principle-Detector i IDoubleCheckValve '�Double Checl<-Detector i IPressurcVacuumBreaker �Spill-Resistant Pressure Vacuum Breaker � 3� ,r Manufacturer �1�`} S Model Number � Size '� Located At l��'�' �e�Z ��Ct�- _Serial Number � z��' 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 lnlet Check Valve � 1 st Check 2nd Check Held at 7�g psid Held at psid Opened at 3� � Opened at Held at Initial Test Closed Tightl I Closed Tight I 1 psid psid psid � Leakedl I Leaked! i Did not open � I Did not open ! Leaked I I Repairs/ � Materials i Used Held at psid Helc1 at psid Test After Opened at Opened at Held at � Repair Ciosed Tight' ! Closed Tight' I psid psid psid I Test gauge used: Make/Model Y��t..o �a`-��T�c SN: z-S�� I Date Tested for Accuracy: � f �((o I Remarks: I The above is certified to be true at the time of testing. /' � ,.,� _� �� I �("� I FirmName l_.�-��I '�"� Firm Address ��3 �+�'��e�-�r �` � �/- I c � � i� Certitied Tester(pr;nr) �V t�� Certified Tester(signature) � '?-`f�'` �— �`�Q -� Date f� 3 l7 � Firm Phonc�_ �1 � Cert.Testcr N�. � * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS I **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yellow-Customer Copy Pink-Tester's Copy i IRRIGAT�ON 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) �'� eo �`I s_S� MAILING ADDRESS: � �3 �rav� PY' CONTACT PERSON/PHONE: LO 1� " S 7-14`4 � "�f040 LOCATION OF SERVICE: $�^ v The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable paratneters. TYPE OF ASSEMBLY �4Reduced Pressure Principle '.-!Reduced Pressure Principle-Detector I Double Check Va1ve ; 'Double Check-Detector i IPressurcVacuumBreaker �Spil1-Resistant Pressure Vacuum Breaker Manufacturer W�'�'+s Model Numbe��'9 m'3 Size 3�`� 1 Located At� YV�e.z� �5 Gl�. Serial Number �µ�f b Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ��S 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 `'7i 1„ psid Held at psid Opened at 3'`{ Opened at Held at Initial Test Closed Tight� i Closed Tight �1 psid psid psid Leakedl I Leaked! ; Did not open i Did not open '; Leaked � � Repairs/ Materials I Used Held at psid Held at psid Test After Opened at Opened at Held at I Repair ClosedTight' ! ClosedTight I psid psid psid i I /� �/ � Test gauge used: Make/Model (�irrr6r�.c� "r4 r Z�� SN: ��p Date Tested for Accuracy: g ��//� Remarks: The above is certified to be true at the time of testing. I I Fir�n Name �'! �� Firm Address �� '�"K °u� �r � p`�� I � I (��. .� I Certitied Tester(prinr) �l�C�1J�� Certified Tester(signature) � I � Firm Phone# � ! ��' ��T� Cert.Tester No. - �� Date � �4 �� * 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 i 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) � /� ��1 I�� MAILING ADDRESS: J�E)� (c�hc2l'��✓��✓��' � �' G � CONTACT PERSON/PHONE: LOCATION OF SERVICE: Q �w 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 -�Red�iced Pressure Principle-Detector � IDoubleCheckValve 'DoubleCheck-Detector Ilpressur�VacuumBreaker iSpill-Resistant Pressure Vacuum Breaker !� Manufacturer �.e'C1e�'�'S Model Number �-FD d 9 � Size ��Z Located At /U yCE /►'1/}(CEj� Serial Number 7�7 Z.� I Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ''�e5 Reduced Pressure Princi le Assembl Pressure Vacuum Breaker i Double Check Valve AssemUly I Relief Valve Air Inlet Check Valve � 1 st Check 2nd Check I Held at 7i�o psid Held at psid Opened at �� Opened at Held at � Initial Test Closed Tight� i Closed Tight I i psid psid psid � Leaked' I Leaked� ', Did not open I Did not open ' :' Leaked I � Repairs/ i Materials � Used � Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight! I Closed Tight I psid psid psid � Test au e used: Make/Model �M.��ct� `t�~�oa��- SN: ��b�� i � g I Date Tested for Accuracy: ��/��(o Remarks: The above is certified to be true at the time of testing. Firm N ame �� e�� -�� Firm A ddress �� LOI`�t � �i:� � `�l �l� � i . � � i Certitied Tester(prant) Certified Tester(signature) � � Firm Phone# ��/" �`C7ro-Ff d� Cert.Tester No.��2�Date � 30 /7 i *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS i **USE ONLY MANUFACTURER'S REPLACEMENT PARTS i i White-City Copy Yellow-Customer Copy Pink-Tester's Copy i 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) r �' MAILING ADDRESS: I 3a3 a 1� �r ef C O N T A C T P E R S O N/P H O N E: G-D lt 5 1�CIS l ` �o `- d�d 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 iReduced Pressure Principle -iReduced Pressure Principle-Detector � IDoubleCheckValve 'Double Checic-Detector ' IPressurcVacuumBreaker ?Spill-Resistant Pressure Vacuum Breaker ��z`� Manufacturer �G��S Model Number �-F ��YYl �� Size Located At S� -�'►-� M P�er Serial Number '1 ( �5�Z Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �P.S Reduced Pressure Princi le Assembl Pressure Vacuum Breaker Double Check Valve Assembly Relief Valve Air Inlet Check Valve � l st Check 2nd Check Held at 7.� psid Held at psid Opened at Z= � Opened at Held at Initial Test Closed Tight( i Closed Tight � I psid psid ps�� Leaked� I Leaked, I Did not open I Did not open ' Leaked I Repairsl Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight i ClosedTight' ! psid psid psid Test gauge used: Make/Model �M�f'GL-+Q ��'�� SN: Z-� ��d Date Tested for A.ccuracy: �/�l�� Remarks: The above is certified to be true at the time of testing. � 303 (,c��t l�- �`✓� FirmName��'-'I �' � Firm Address � , � w Certified Tester(pr�nt) Certified Tester(signature) � �� —�]�`�� Cert.Tester No.� �� Date (O 3v Firm Phone# � *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