2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assembly tested. :� si�iled and dated oribinal
n�ust be submitted to the public water supplier for recordkeeping�iu-poses:
BACKFLOW PIPE�TENTION ASSEMSLY TEST Al�'D 1RAINTEN��lNCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Club Circie Dr Coqqell TX 75019
CONTACT PERSON/PHONE:Denise 214-930-0933
LOCATION OF SERVICE: _/d/t� 7.,.el,a�aHil,oh �
The backtlow prevention assembly detailed belo�•has been tested �nd maitrtained as required by
commission re�ulations and is ccrtified to be operating���ithin acceptablc�arameters.
'I'YPE OF ASSEl�IBLI'
Reduced Pressure Principle Reducec� Pressure Principle-Detector
X Double Cl�eck Valve Do�ible Checl;-DeTector
PressurcVacuumBreaker Spi1l=Resistant Pi•essure Vacuum Breaker
ivlanufactui•er_ f}-rv�5 Vlodel Number Z[�D � Size i"
Located At Serial Nunlbcr /(Qp�
Is the assembly insta ed in accordance with manufacturer recomnlendations and/or local codes'? PS
Reciuced Pressure Princi le Assemblv Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�'^''" Heid at�psid H�ld at �,(o psi Opeiied at C�prncd at Hcld at
lniti�l Test Closed Tight ✓ Closed Tight � psid psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Hcld ai psid
Test After Opei�cd ut Opened at Held at
Repair Closed Tight ' Closed Tight psid psid �sid
Test gauge used: Make/Model AooIIQ40-200-tk5u Si�1: 04.142g67
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin,.
Finn Name Diamondback Fire Protection Firnl Address_ PO Box 2507.Waxahachie.TX 75168
Certiticd Testcr(pr;��t�oe Standrida8 Certitied Tester(signature
Finn Phonc# (214) 444-3194 Cert.Tester�:o. BP0015823 I�atc 10/23/2015
�TEST RECORDS ivIUST BE KEPT FOR AT LEAST Tl-IREE YEARS
�*USE ONLY MANUFACTURER'S REPLACEA�ENT PARTS
White-City Copy I'eliotv-Customel•Copy Pink-Tester's Copy