2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following forin must be completed for each assembly tested. A si�ned and dated original
must be subinitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST A14'I3�.�i�ITENfl�CE REPORT
NAME OF PWS: CITY OF COPPELL AVvS I.D. #05700�0
(Customer) �
MAILING ADDRESS: 253 Club Circf Dr Co�pell TX 75019
CONTACT PERSON/PHOIVE:D ni 214-
LOCATtON OF SERVICE: l rV \
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certiticd to be operating�i=ithin acceptable��araji��ters.
T'�'PE O�'�SSEIV�BI.I'
� Reduced Pressure Principle Reduced Pressure Princip(e-Detector
X Double Check Valve Double Chec}:-Detector
PressurcVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer�y,��y �lodel Numbe�•_�n g Size �
LUc�ted f1t_�r.�„_ti � Serial N�unber OSlo S�
Is the assembly installed in accordance with mauufacturer recommendations and/or Iocal codes'?y�
Reduced Pressure Princi ie�ssembl�r Presstire�'acuum Breaker
Double Cl�eck Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�,SS
Held at�.(o psid Held at 1•2 psid Qpcncd at Opci�ed�t Heid at
Initial Test Clnsed Ti�ht ✓ Closed Tight ✓ psid �zS1� ��y��i
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used !
Held at }�sid Held at psid �
Test After Opei�cd at Opcned at Held at
Repair CJosed?ight ' Closed Tight : pS�d psy� psid
Test gauge i►sed: Make/Model oll 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true ak the time of testin,.
Firm Name Diamondback Fire Protection Finn Address PO Box 2507 Waxahachie TX 75168
Certiticd Tester(�,r;r:t�Qe Standridge Certitieci Tester(signat�u-
Firm Phonc#(214)444-3194 Ce��t.Testca•;�o. BP0015823 Date 10/23/2015
� TEST RECORDS MUST BE KEPT FOR AT LEAST THREE 1'EARS
M�USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy �'ello�v-Custonler Copy Pink-Tester's Copy