2015_1023 IRRIGATION DOMESTIC F1RELlNE X
The followin� form must be completed for each assembly tested. A si�ned and ciat�d oribinal
must be submitted to the public��vater supplier for►-ecordkeepi►lg piu-poses:
BACKFLOW PRE�'ENTION,4SSEMBLY'TES'i'AND 1�1�I�1TEN�NCE REPORT
NAME OF PWS: CITY QF COPPELL PVvS I.D. #0�70040
(Gustomer)
MAILING ADDRESS: 253 Club Circle Dr Connell TX 75019
CONTACT PERSON/PHONE: Dernse 214-930-0�33
LOCATION OFSERVICE: �Q� �,�o�„��p
The backflow prevention assembly detailed belo«�has been tested and maintained as required by
commission regulations and is ccrtiticd to be operating within aecept�blc t�ai-�meters.
TYPE OF A�SEI��BLY
� Reduced Pressiu-e Principle Reduced Pressure Principle-Detector
X Double Check Valve Doiible Checl:-Detector
PressureVacuumBreaker Spi1l=Resistant Fressure Vacuum Breaker
Manufacturer�y�.. g t�Iodel Numbe�• ?l�d Size ��' _
Located !�t C-to.ee�a Serial Numher
Is the assembly installed m accordance with mauufacturer recam�nendations and/or local codes?
Reduced Prc:ssure Princi �e Assemblv Pressure Vacuum Breaker
Double Check Valve AssemUly
Relief Valve Air Iillet Check Valve
t st Check 2nd Check
'Yb�� Held at 2.•O sid Held�t 1 ,'�1
p, � p;id Opencd�lt_, Opcned at Heid at
Initial Test Closed Tight✓ Clused Tight ✓ psid ps��� ��y��{
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Test After Held at psid Hcld at psid
Opcncd at i Opcned at Held at
Repair Gosed Tight ' Closed Tight-_� psid �sid ��si�
Test gauge used: Make/Model��a��o 40-200-tk5y SN: 04142867
Date Tested for Accuracy: _ 5/4/2015
Remarks:
The above is ce�tified to be true at the time of testin�.
Fi�7n Name Diamondback Fire Protection Finn Address PO Box 2507 Waxahachie TX 75168
Certit7ed Tester(p�-;��t�Qe Standridge _CertiYiecj Tester(si��iatin-e)
Firm Phanc#(214)444-3194 Cert.Testcr\o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�� USE ONLY MANUFACTURFR'S REPLACEIVIENT PARTS
White-City Copy Yellovv-Customer Copy Pink-Tester's Copy