2015_1023 IRRIGATION DOMESTIC �=1RELINE X
The following form must be completed for each assembl_y test�a. A �i�ned and dated original
must be subiuitted to the public watcr supplier for recordkeeping purp�ses:
BACFCFLOW PRE�'ENTIOIl1 ASSEI�'[ELY TES�'f#�,`D i1�:�I�TENtl�4CE REPORT
NAME OF PWS: CITY OF COPPELL PWS LD. #0570040
(Gustomer) ��
MAl LING ADDRESS: 253 Club Circle Dr Cot�ell TX 75019
GONTACT PERSOiv'/PHONE: D ni 214- -0
LOCATION OF SERV ICE: /c�I l �,,,,�J,vnAn ,oy��e
The backflow prevention assembiy detailed be o«�l�as been tested and �naintained as required by
�ommission re�ulations and is ccrtitied to be operating��-ithin acceptablc��aramet�rs.
'TYPE O�ASSEI�IBLI'
Reduced Pressure Principle Red�.iced Pressure Principle-Detector
X Double Check Val��e Doubl�; Checl;-I�etector
PressurcVacut�mBreaker 5pi11=Resistant Pressure Vacuum Breaker
Manufactui•er�-�g �iodel Number 2Cx�O,g Size {'�
Located At_�r�_�� _S�rial Ni�mber �lo L�(
Is the assembly mstalled m accordance with manufacttuer recommendations andr`or local codes'?
Reduced Pressure Princi le/lssemblv f'ressure\%acuum Breaker
Double Check Valve Assembly
1 st Check � Relief Vah�e Air Intet Check Valve
nd Check
P�`�5 Helcl at sid Held at 1,
��p• _�psid Opened at Opcned at Held at
Initial Test Closed Tight✓ Closed Tight ✓ psid psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Hcld at ��sid
Test After Opeacd at Opcned at Held at
Repair Closed Tight ' Closed Tight ps�d }�s�� �sfd
Test gauge used: Make/Model__��l0 40-200-ik5u SN: 04142867
Date Tested foc Accuracy: 5/4/2015
Remarks:
The above is ceitified to be ti•ue at the time of testing.
Firm Name Diamondback Fire Protection Firn� Address PO Box 2507. Waxahachie TX 75168
�Certiticd Tester(pr:��t�oe Standrida� Certitied Tester(sicnature�i���� "
Finn Phonc#(214)444-3194 Cert.Testci-�o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LE�ST'THREE YEARS
��USE ONLY MANU�ACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy