2015_1023 IRRIGATION DOMESTIC FIRELlNE X
The following form must be completed for each assembly test�d. A �igned and dated ariginal
must be submitted to the public��vater supplier for recordkeeping p��i-poses:
BACFCFLOW PI�E��'ENTIOI�I ASSEMSLY'i'ES'6'Ah`D 1�.�I�TENflNCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�700�0
(Customer) �
MAILING ADDRESS: 253 Club Circle Dr Cop�ll TX 75019
CONTACT PERSON/PHONE: Denise 214930-0933
LOCATION OF SERVICE::_/(7C?� �„�,0��40,oy�,�o
The backflow pre��ention assembly detailed belo«r has been tested and maintained as reqtiired by
commission reaulations and is certiticd to be e�perating�vithin acceptable��ai•ameccrs.
7�'YPE OF ASSEI�IBL,Y
Reduced Pressure Principie Red«ced Pressure Principle-Detector
XDoubleCheckValve Double Checl:-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer �w.:t.s �lodel Number 2C)�f3 Size �"
Lacated At C,���� Serial Number 139Z3
Is thz assetnbly installed in accordance with manufacturer recommeridatioils and/or local codes?
Reduced Pressure Princi le Assemblv Pressi�re Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Vafve
i st Check 2nd Check
F�' Held at �.Z psid Held at��psid Opencd at__ O��ned at He(d at
Initi�l Test Closed T'Ight✓ ClosedTight ✓ psid psic! psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at ��sid
Test After Opci�rd at Upened at Held at
Repair GosedTight l ClosedTight psid psid psid
Test gau�e used: Make/Mode1_�qnollo 40-200-tk5u SN:_04142867
Date Tested foc Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin,.
Firm Namc Diamondback Fire Protection Firnl Address PO Box 2507. Waxahachie.TX 75168
�Cei-tified Tester(�r�r�t�oe Standridae C'ertified T'ester{signattu-e;
Firm Phonc# (214)444-3194 Ci;rt.Testcr\o. BP0015823 I)ate 10/23/2015
�TEST RECORDS ivIUST BE KEPT FOR AT LEAST THREE YEARS
T* USE ONLY MANUFACT'URER`S REPLACEMENT PARTS
White-Gity Copy � 4'ello�v-Customer C'opy Pink-Teste�'s Copy