2015_1023 IRRIGATION DOMESTIC �=1RELINE X
The followi��g form must be completed for each assei»bly test�d. � si`i�ed and dat�d ori�inal
must be submitted to the public water supplier for recordkeeping purposes
BACKFL4W PREVEI�ITION ASSEMSLY TESTA�,'D�[AI�iTEN.�tiCE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Club Circfe Dr Co�pell TX 75019
CONTACT PERSON/PHONE:�enise 214-930-0933
LOCATION OF SERVICE: It��?T�,,,,��21�,e.�
The backflow prevention assembly detailed belo«�has been tested and maintained as required by
commission re��ilations and is certiticd to be operating�vithin acceptablc��ai•a�neters.
'FYPE OF ASSEI@�gBI.I'
Reduced Press«re Principle Red�iced Pressure Principle-Detector
XDoubleCheck Valve Double Checl:-Detector
Pressurc VacutunBreaker Spill=Resistant Pressure Vacuum Breaker
Manufactui•er f�„,�� ivlodel Number 2�pc� (� Size I`.
Located �t CTo�.re„o, _Serial Number (t-X�C� �q
Is the assembly installed in accordance with mam�facturer recommendatious ancU'or local codes'?
Reduccd Pressure Princi 1e Assemblv f'ressure Vacuum Breaker
Double Clieck Valve Assembly
Relief Valve Air lnlet Check Vafve
1 st Check 2nd Check
i'�'"'' Held at�'L.2 psid Held at � .2 p;id Open�d at�_ Op�ned at Hcid at
Initial Test Closed Tight✓ ClosedTight ✓� psid psicl py��
Leaked ' Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Hcld at psid
Test After Opeu�d af � Opcned ai � Held at
Repair Closed Tight : Closed Tight:
psid psid psid
Test gauge used: Make/Model Aoolla 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the ti���e of testina.
Fit-m Name I�iamondback Fire Protection Finn Address PO Box 2507 Waxahachie TX 75168
Certiticd Testcr(pr:�,t�oe Standridae Certitied Tester(signature
Finn Phonc#_(214)444-3194 Cert.Test�r�a. BP0015823 _ Date 10/23/2015
�TEST RECORDS iVIUST BE KEPT FOR AT LEAST THREE YEARS
*�USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy �'ello�v-Customer Copy Pink-Tester's Copy