2015_1023 IRRIGATION DOMESTIC FlRELlNE X
The following form must be completed for eacll assembly tested. A �i�ned and ciated oriDinal
must be submitted to the public water supplier for recordkeeping p��rposes
BACKFLOW PRE�rENTION ASSEMBI.Y TEST ANI�±l�1����7'�N�i�CE REPORT
NAME OF PWS: CIT'Y OF COPPELL PVvS I.D. #4�70040
(Customer)
MAILtNG ADDRESS: 253 Club Gircle Dr Conp�l{ TX 75019
CONTACT PERSON/PHONE. D rn 214- 9 3
LOCATION OF SERVICE: 102� Co1E,,,�,� ,
The backflow prevention assembly detailed belo«�has been tested and mairrt�ined as required by
commission regulations and is certiticd to be operating�vithin acceptable C�arameters.
7'YPE OF�SSEI�II�LI'
Reduced Pressure Principle Reduce�i Pressure Principie-Detector
XDoubleCheckVal��e Double C11ecl;-Detector
PressureVacut�mBreaker Spi]1=Resistant Pressure Vacuum Breaker
Manufactui-er�,��� l�Iodel Number_�jp "
� Size�_
Located At_��a,p�Q Serial Number�e��..,�
Is t11e assembly installed in accordance with manufacturei•recommendatioils a�id/or local codes'?
Reciuced Pressure Princi le Asscmblv PresSure V��uum Breaker
Double Check Valve Assembly
Relief Val�-e Air Inlet Check Valve
1 st Check 2nd Check
� �r� Held�t�psid Held at �1 s�d O�cned at �
0�" 1L.P'� f (�prned at Hc(d at
Initial Test Closed Tight✓ Closed Tight ✓ psid psic! py��
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Test After �`l�`�t �sid Hcld at psici �
Opencd at U�ened at Held at
Repair Closed Tight Closed Tight sid
P psid psid
Test gauge used: Make/iYfodel�nollo 40-200-tk��� SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Firm Name Diamondbadc Fire Protection Finn Address_ PO Box 2507 Waxahachie TX 75168
Certified Tester(p�-;��t�oe Standridge Certitied Testei�(signatiu-e)
Firm Phane#(214)444.-3194 Cert.Testea-�o. BP0015823 Date 10/23/2015
'�TEST RECORDS MUST BE KEPT FOR AT LEaST THREE YEARS
�*USE ONLY MANUF�CTURER'S REPLACEUIENT PARTS
White-Gity Copy Yello�v-Customer�'opy Pink-Tester's Copy