2015_1023 1RRIGATION DOMESTIC r!RELiNE X
The following form must be completed for eac11 assembly testeci. A ;igned and dated original
must be submitted to the public water supplier for i-ecordkeepi►lg pui-poses:
BACI{FLOW PRE�'ENTION ASSEMBLY TESTAI�'�1�9.�I�TEN�NCE REPORT
NAME OF PWS: CITY OF COPPELL PVi%S I.D. #0�7Q040
(Gustomer) � � �
MAILING ADDRESS: 253 Club Circ�P Dr Copqell TX 75019
CONTACT PERSON/PHONE: p i 14-9 -0 3
LOCATION OFSERVICE: � ,o�P�
The backflow prevention assembly detailed belo���has been tested and n�aintained as required by
commission regulatians and is c�rtiticd to Ue operating���ithin accept�blc��ai•ameters,
7'YPE OF�SSEI�I�L�'
Reduced Pressure Principle Reduced Pressure Priuciple-Detector
XDoubleCheckValve Double Clieci;-Detector
Pressurc VacuumBreaker Spi]1=Resistant Pressure Vacuum Breaker
Manufacturer �t w•eS tYlodel Number ZC�nO t3 Size ('�
Located f�t _Serial Number J(o )9
Is the assembly installe in accordance with inamifact�u-er recommendations ancU`or local codes'?
Reduced Pressure Princi le Assembh- Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
f st Check 2nd Check
�a� Held at �•� sid Held at e�
}�, ���iiICI O(7C(l�(j at__ Opcncd at Hcld at
� Initial Test Closed Tight ✓ ClusedTight ✓ psid E�sid �psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psict Held at ��sid
Test After Opeucd at O��ened at Held at
Repair Closed Tight : Closed Tight psid psid psid
Test�auge used: Make/Model Anollo 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is eertified to be true at fhe time of testing.
Finn Na�nc Diamondback Fire Protection Finn Address PO Box 2507, Waxahachie TX 75168
Certitled Testcr(�r;�t�oe Standridae Certitieti T�,ste��(si���att�rej
Finn Phonc# (214) 444-3194 Cert.Tcstcr\o. BP0015823 I�ate 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEaST THREE YEAR5
�* USE ONLY MANUFACTURER'S REPLACEMENT('ARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy