2015_1023 IRRIGATION DOMESTIC FlRELI�JE X
The following form irnist be completed for each assembly test�d. A signed and ciated aribinal
must be submitted to the public��vater supplier for recordkeeping puiposes:
BACKFLOW PREVENTION ASSEMBLY TEST Ah`I�VflAI�4TENA�CE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. # 0�700�0
(Customer)
MAILING ADDRESS: _253 Club Circle Dr Go�nell TX 75019
CONTACT PERSON/PHONE:�enise 214-930-0933
LOCATION OFSERVICE: 10�� C��,.,,.,.� 1
The backflow pre��ention assembly detailed belo«�has been tested and maintained as required by
commission re�ulations and is ccrtificd to be operating�i°ithin accepTable p�rameters.
�'To'PE OF�SS�1��L�' �
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Check Valve Do�ible Check-Detector
PressureVacutunBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufactui-el• u� Ivlodel Numbe�- "
�1� Size�_
Located At �, � Serial l�lumhec C95�$�j
Is the assei��bly installed in accordance witl�manufactw-er recommendations andior local codes'?
Reduced Fressure Princi le Assemblv Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
� Held at J�_psid Held at l�fn psid O��encd at O�cn�d at Held at
Initial Test Closed T'igllt✓ Closed Tight ✓ psid psi�l ps��j
Leaked Leaked Did not open I�id not open Leaked
Repairs/
Materials
Used
Held at psid H�id at psid
Test After Upencd at Opened at Held at
Repair Closed Tight Closed Tight ps�d ��si� �sfd
Test gauce used: Make/Model �oll0 40-200-tk5u SN: 04142gg7
Date Tested foc Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin�.
Fii7n Naine Diamondback Fire Proteetion Finn Address PO Box 2507. Waxahachie TX 75168
Certificd Tester(�r;�-:t�oe Stan�ridae Certitieci Tester(si��naC«re)�
Finn Phonc# (214� 4443194 Cert.Testcr io. BP0015823 D��te 10/23/2015
%TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
��USE C)NLY MANUFACTURER'S REPLACENIENT PARTS
White-City Copy I'ello���-Customer Copy Pink-Tester's Copy