The URL can be used to link to this page

2017_0925 IRRIGATION DOMESTIC � FIRELlNE 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) �7 MAILING ADDRESS: � fl3 V� ' l,�✓ el1 CONTACT PERSON/PHONE: � ' � ��I— (o— O'�D LOCATION OF SERVICE: 4CX� 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 �ClDoubleCheck Valve IDouble Checl<-Detector f 1 Pressur�Vacuum Breaker 'Spill-Resistant Pressure Vacuum Breaker Manufacturer�Q�c� Model Number �� 1� � � Size 2t� Fet� /� Located At�A�ti'�=��bF.L i � .,PcC�i Il'1Cyc'�� Serial Nuinber f� g'�a�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �eS 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 [nitial Test Closed Tight!� Closed Tight � psid psid ps�� Leakedl I Leakedl I Did not open i Did not open ' Leaked � Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' ! Closed Tight I psid psid psid Test gauge used: Make/Model �—O�b�� 4��'Z�� SN: z•�� Date Tested for Accuracy: ��/7 Remarks: The above is certified to be true at the time of testing. FirmName �—Ej(J��..'�� .1—�p � Firm Address �W� �r. Certitied Tester(p►-;nr)��5�\ Certified Tester(signature) � � Firm Phone# 7s��"�"f�� b Cert.Tester No. �P��J� Date 9 Z5 /�7 *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 FIRELWE 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: 13 n� ��`a� (�-r �ir. Ct� P�I �'X � `��S CONTACT PERSON/PHONE: �c� � LOCATION OF SERVICE: �100 Cow�'J6v 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 �Reduced Pressure Principle-Detector ; I Double Check Valve 'Double Check-Detector ' IPressurcVacuumBreaker `'Spill-Resistant Pressure Vacuum Breaker Manufacturer 1—��C.o Model Number g S�� Size Z r� Located At [�`c.lc�-� �1�00��•- �R'T� # � Serial Number f��'��a� 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 Z�S psid Held at ��cf psid Opened at �pened at Held at Initial Test Closed Tightil� Closed Tight 11�' ps�d Ps�d Us�� Leakedl I Leaked' I Did not open I Did not open ! Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair Closed Tight' ! Closed Tight� I ps�d psid psid Test gauge used: Make/Model ��r,Wtb�'a-� �D--�f�0 �fK-- SN: Z 5�dn� Date Tested for Accuracy: ]/�.�/7 Remarks: The above is certified to be true at the time of testing. — ��o� ��1� �''� Firm Name I I -1—J Firm Address , f Certitied Tester(pr:nt)�� t�Certified Tester(signature) Finn Phone# Z�� '��1�^gG�{D Cert.Tester No. dPQC7��7S� Date / �'S � * 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: 13�3 � �� K ,�� CONTACT PERSON/PHONE: l� � .l Z�4 -y l�-- O�o LOCATION OF SERVICE: �b� Coc.�% - The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable paraineters. TYPE OF ASSEMBLY iReduced Pressure Principle '.-1Red�iced Pressure Principle-Detector � IDoubleCheckValve '�Double Check-Detector '1Pressurc:VacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �� Model Number ��d Size �� Located At T'��' 8�c�� G�Tf�� Serial Number f7 ��o� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? vCS Reduced Press�ire Princi le Assembl Pressure Vacuum Breaker Double Check Valve AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at �� psid Held at ��5 psid Opened at Opened at Held at Initiai Test Closed Tightirb Closed Tight i� psid psid ps�� Leakedl I Leaked' I Did not open i Did not open ' Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight ', ClosedTight I I ps�d ps�d psid Test gauge used: Make/Model �M�c1� ��'- �a �� SN: 2S��U Date Tested for Accuracy: ��IB'T 7 Remarks: The above is certified to be true at the time of testing. FirmName �� -�-s� Firm Address l�� W �� r• Q � � � Certified Tester(pr�nt) aV i� �Ol� Certified Tester(signature) Firm Phone# ��'�� "�� Cert.Tester No.d�l Q�°�� Date/ �'b� �7 * 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 u DOMESTIC FIRELlNE 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) ,,7 S D t MAILING ADDRESS: [30` ✓ �Y �� x CONTACT PERSON/PHONE: : � Z-� '`� � "" �`� LOCATION OF SERVICE: �b C�� — 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 -�Reduced Pressure Principle-Detector �IcDouble Check Valve 'Double Check-Detector IPressur�VacuumBreaker !Spill-Resistant Pressure Vacuum Breaker � z�, Manufacturer t-2�Gd Model Number �S O Size Located At %'c��e� �Qo'�� Serial Number�� 7�� Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �e� 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 �i Z psid Held at 1'.la psid Opened at Opened at Held at Initial Test Closed Tight'`� Closed Tight b�f psid psid ps�� Lealcedl 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 ClosedTight I ClosedTight' ! psid psid psid Test gauge used: Make/Model �MD�^iz Co '7'a'� �d � SN: �� Date Tested for Accuracy: y�� Remarks: The above is certified to be true at the time of testing. �� , Firm Name �� Firm Address ��r� t��:�`T`-" Certit7ed Tester(pr�nt) � Certified Tester(signature) � ^ Firm Phone# ��T ``'� 1�'�0�V Cert.Tester No. ��l�4 Date / �� 7 *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS White-City Copy Yeltow-Customer Copy Pink-Tester's Copy IRRIGATION N DOMESTIC FIRELINE The following form must be completed for each assembly tested. A signed and dated original must be submitted to the p�iblic water supplier for recordkeeping purposes: BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF COPPELL PWS I.D. #0570040 (Customer) (� ,� � �� — -'S-Q i� MAILING ADDRESS: I rQYI 'PY `'� CONTACT PERSON/PHONE: ZI�{- H � f) LOCATION OF SERVICE: 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 iReduced Pressure Principle '-IReduced Pressure Principle-Detector �y4DoubleCheckValve ',Double Clleck-Detector � IPressurc:VacuumBreaker iSpi11-Resistant Pressure Vacuum Breaker r ��Q `� Manufacturer /—e�L E� Model Number Size_�__ Located A��ce� h��h. � � Serial Number /'r Q�� (0 0 Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ' eS 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 Z��psid Held at Z,� psid Opened at Opened at Held at Initial Test Closed Tight?� Closed Tight�I psid psid psid Leakedl I Leakedl I Did not open I Did not open ' ' Leaked. I Repairs/ 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 �i'v� '�``�- ��'� SN: Z-��ad0 Date Tested for Accuracy: �` Remarks: The above is certified to be true at the time of testing. C�, �elr � 3�� c�-a 9 l� ��- Firm Name P� �� Firm Address --� . � Certified Tester(pranr) � V 1` t r Certified Tester(signature) Finn Phone# ��`T— 'Tg� C��`tU Cert.Tester No.l7T"Q�b'� Date 7 �� 7 * 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) n /� MAILING ADDRESS: �3G 3 �t'ar��f-r l-:� l�o��I( �X CONTACT PERSON/PHONE: 1 �; Z( `�` `f��-�$�`f� LOCATION OF SERVICE: The backflow prevention assembly detailed below has een tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. TYPE OF ASSEMBLY ` iReduced Pressure Principle '-�Reduced Pressure Principle-Detector �oubleCheck Valve !Double Check-Detector f IPressur�VacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker Manufacturer �2� �-� Model Number ��Q Size Z Located At �_fee-1� �i�� /rF1'(� �� Serial Number ��J Is the assembly installed in accordance with manufacturer recommendations and/or local codes? �E'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 ��5 psid Held at Z�� psid Opened at Opened at Held at Initial Test Closed Tight��G Closed Tight i 71� psid psid psid Leakedl I Leakedl ; Did not open i 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�fam��.ev �p - Z� �i(� SN: Z-5�f0o� Date Tested for Accuracy: /�/�1/I 7 Remarks: The above is certified to be true at the time of testing. Firm Name �� 5D Firm Address � ?J�� Gc/Y'W1 e� �r (� , � , Certitied Testcr(pr�nt) �I�t i1e Q� a/ � Certified Tester(signature) Firm Phone# �"T ��'"�� Cert.Tester No.�l��i�7�g Date�� /�7 * 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 k 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 r MAILING ADDRESS: � �'l.�►1 � 1° i r I � CONTACT PERSON/PHONE: 1 ` � ` � �- �`� LOCATION OF SERVICE: CJ t 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 '-!Redticed Pressure Principle-Detector �(1Double Check Valve ':'Double Check-Detector � IPressur�VacuumBreaker 1Spi11-Resistant Pressure Vacuum Breaker �i Manufacturer �e�t o Model Number �5�L Size � Located At �C.L�� Doo�� C,a-T��G 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 AssemUly Relief Valve Air Inlet Check Valve 1 st Check 2nd Check Held at�psid Held at�psid Opened at Opened at Neld at Initial Test Closed Tightb'� Closed Tight �I° psid psid psid Leakedl I C,eaked! � Did not open I Did not open : Leaked I Repairs/ Materials Used Held at psid Held at psid Test After Opened at Opened at Held at Repair ClosedTight' � ClosedTight� I psid psid psid Test gauge used: Make/Model�t"//22�c� "�"�'�� SN: �� Date Tested for Accuracy: �� ? Remarks: The above is certified to be true at the time of testing. ` �-�,n / 1 r Firm Name ��e(� L�JJ Firm Address W �r �'�`7�� , ` Certitied Tester(pr�nr) ` Certified Tester(signature) Finn Phone# "��l� +�Q`-��Cert.Tester No.�__�_Date � d��J /7 *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