2015_1023 IRRIGATION DOMESTIC FlRELlNE X
The following form must be completed for each assembly tested. A �igned and dated original
must be submitted to the public water su�plier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST tlfa`D:VIAIlTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PVvS LD. #0�70040
(Customer) �
MAILWG ADDRESS: 253 Club Circle Dr Co�pell TX 75019
CONTACT PERSON/PHONE: Denise 214-930-0933
LOCATION OFSERVICE: lppS� Cf,�..,,r;.�
The backflow pre��ention assembly detailed belo«�has been tested and maintained as requircd by
commission regulations and is certiticd to be operating���ithin�tccepiable��t�ramet�rs.
'TYPE OF�SSEI�IBLI�
Reduced Pressure Principle Reduced Pressure Principle-Detector
XDoubleCheck Vat��e Double Check-Detecror
PressureVacuumBreaker Spill=Resistant Pressure Vacuum Breaker
Manufactui-er�,�,�,, �Iodel Numbe�__�R Size l��
Located At e. Serial t�iiunber OS2��
[s tlle assembly installe in accordance with tnauufact�u-er recommendations anci�'or local codes'? VfS
Reduced Fressure Princi ie Assembhf Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Chcck Valve
1 st Check 2nd Check
P�� Held at��psid Weld at �-(opsfi Opened at Oprned�it Held at
Initial Test Closed Tight ✓ Closed Ti�ht ✓ psid psi�l ��y��
Leaked Leaked Did not open Did uot open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
� Test Aiter Qpeucd at Opcued at � Held at
Repair Closed Tight ' Closed Tight �S�d ps�� psid
Test gauge used: Make/Model Ilo 40-200-tk5u S1�1: 04142867
Date Tested for Acctu�acy: 5/4/2015
Remarks:
The above is certified to be true at the time of testi��g.
Fii7n Namc Diamondbadc Fi�e Protection Firnl Address PO Box 2507 Waxahachie TX 75168
Certificd Testc,•(r�-i s-:t�oe Standridqe Certified Teste2•(si��nat�u�
Firm Phonc# (214)444-3194 Cert.Testcr\o. BP0015823 D�lte 10/23/2015
� TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�* USE ONLY MANUFACTURER`S REPLACEiV1ENT PARTS
White-City Copy I'ello�v-Customer Copy Pink-Tester's Copy