2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be comp]eted for each assem6ty tested. A sig��ed and daizd ori�inal
must be submitted to the public water supplier for recordkeeping p�n-poses:
BACI{FLOW PRE�'ENTION ASSEMBLY TES�'Al4'D 1���€�iT�'VANCE REPORT
NAME OF PWS: CITY OF COPPELL Pu�S I.D. #0570040
(Customer) � �
MAILING ADDRESS: 253 Club Gircle Dr Cop�ell TX 75019
CONTACT PERSONIPHONE: Dernse 214930-0933
LOCATION OFSERVICE: 11�1-a- ('nlor►.s�
The backflow prevention assembly detailed belo«�has been tested and maintlined as required by
commission re=ulations and is certificd to be operating���ithin acceptable��ai-ameters.
'f'YP�OF ASSEI�IBLI�
Reduced Pressure Priilciple :Reduced Pressure Pi•inciple-Detector
X Double Check Val�-e Double Check-Detector
PressureVacuumBreaker Spill=Resistant Pressure Vaaium Breaker
Manufactui•er_ ��,,,��,� �Iodel Numbe�- 2pc9p � Size ���
Located !tt C-;,sr d _Serial Numbcc_p�Cp��
Is the assembly iiistalted in accordance v�jith manufacturer recominendations and/or local codes'?
Reduced Pressure Princi le Assemblv Pressure Vacuum Breaker
Double Cl�eck Valve Assembly
Relief Valve Air Inlet Check Vaive
�l st Check 2nd Check
��"'" Held at�l�psid Held at�psid Opentd�tt Oprncd at Held at
Initial Test Closed Tigllt✓ � Closed Tight ✓ psid � ��yi�� ��y���
Leaked Leaked Did not open I�id not open Leaked
Repairs!
Materials
Used
Held at psid Hcld at psid
Test After �pened at Upcned at Held at
Repair Closed Tight ' Closed Tight �S�d ps�� psid
Test sauge used: Make/Model oll0 40-200-tk5� SN: 04142867
Date Tested for Acctiracy: 5/4/2015
Remarks:
The above is ceitified to be true at the time of testina.
Firm Name Diamondbadc Fire Protection Finn Address PO Box 2507 Waxahachie TX 75168
Certificd Testci-(pi-;s-t?Joe Standridae Certitied Testei•(signatui-e;
Firm Phonc#(214)444-3194 Cert.Testcr Na. BP0015823 Datc 10/23l2015
�TEST RECORDS iVIUST BE KEPT FOR AT LEAST THREE YEARS
��USE ONLY MANUFACTURER'S REPLACENtENT PARTS
White-eity Copy Yello�v-Customer Copy Pink-Tester's Copy