2015_1023 IRRIGATION DOMESTIC FlftEUNE X
The following form must be comp]eted for each assembly tested. A �i�ned and ciated original
must be submitted to the public water supplier for recordkeeping p�u-poses:
BACKFLOWPRE�'ENTION:�SSEMSLY'I'ESTA14'D ViAI��TE:N�NCE REPORT
NAME OF PWS: CITY OF COPPELL P�h%S I.D. #0�700�0
(Gustomer)
MA1L[NG ADDRESS: _253 Club Circle Dr Coppell TX 75019
CONTACT PERSOi�i;PHONE:_penise 214-930-0933
LOCATION OF SERVICE: /pG,S Colr�►-ti�
The backflow pre��ention assembly detailed belo��has been tested and maintained as required by
commission regulations and is certificd to be operating���ithin acceptable t�ar�meters.
� TYPE OF A�SEll���I.I' �
- Reduced Pressure Principle Reduced Pi-essure Priuciple-Detector
XDoubleCl�eck Valve Double Check-l�etector
PressurcVacutunBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufactui•er_ Q�� 1��lodel Numbes ZOpC`�� Size I"
Located At C�,�p�p�� _ Serial �lumber C��q�l
Is the assembly installed in accot•dance with matnifacturer recommendations and/or local codes'? VES
Reduced Presst�re Princi le AssembhJ Pressure Vacinim Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
!st Check 2nd Check
`�s Held at �•g psid Held at�psi Opencd at O�cned at Heid at
Initial Test Closed Tight✓ Closed Tight � psid psic! psi�{
Leaked Leaked Did not oUen Did nat open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opei�ed at Opened at Held at
Repair Closed Tight Closed Tight ps�d ps�� psid
Test gauge used: Make/Model 0110 40-200-tk5u SN: 04.142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is ce�tified to be true at the time of testin,.
Fi�7n Name 9iamondback Fire Protection Finn Add�-ess_ PO Box 2507. Waxahachie TX 75168
Certified Test�r(pr;�-:t�oe Standridge Certif►ed Tester(signatur
Finn Phone#(214) 444-3194 Cert.Tester No. BP0015823 Date 10/23/2015
�TEST RECORDS ivIUST BE KEPT FOR AT LEAST THREE YEARS
'�� USE ONLY MANUf�ACTURER'S REPLACEMENT PARTS
White-City Copy Yello��r-Customer Copy Pink-Tester's Copy