2015_1023 IRRIGATION DOMESTIC F}�ELINE X
The following form must be completed for eac11 assembly testecl. A signed and ciated ot-ioi�lal
must be submitted to the public water supplier for recordkeeping pt►rposes: '
BACICFLOW PRE�'ENTION ASSEMBLY TEST A14'Q M.�I��ENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�7Q0�0
(Gustomer) �
MAILING ADDRESS: 253 Gl�b Circle Dr Co� Ine I TX 75019
CONTACT PERSON/PHONE: D i 214-
LOCATION OF SERVICE: /t�/•,/ Z„�n ,.�
The backflow prevention assembly detailed belo�°has been tested and maintained as rec�uired by
commission re�ulations and is certified to be o�erating�i-ithin acceptable�arametea�s.
'I'YPE OF�SSEIV��LI'
Reduced Pressure Principle Reduce€� Pressure Priucip[e-Detector
X Double Clleck Val�•e Double Cliecl:-I�etector
PressureVacuu�nBreaker Spi1l=Resistant Pi•essure Vactium Breaker
Manufacturer_ �w•.t� �1ode1 Numbe�- 2_�`Y�t9R Size lu
Located At_�� Serial Nuinber �5�jy
Is th�assembly installed in accordance with rnanufacttuer recommendations ancL`or local codes'? �S
Reduced Pressure Princi le Assemblu Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
�� Helcl at"��psid Held at psid O�ened at Oprned at Held at
Initial Test Closed Tight ClosedTight psid psid �sid
Leaked✓ Leaked Did not open Did not open Leaked
Repairs/ � �
Materials
Used
Held at psid Held at psid
Test After Openid at Opcned at HeJd at
Repair Closed Tight ` Closed Tight , psid psid psid
Test�auge used: Make/Modcl oll0 40-200-tk5u SN:__44142867
Date Tested for Accuracy: 5/4/2015
Remarks_
The above is certified to be true at the time of testing.
Fi�-�n Name Diamondbadc Fire Protection Finn Address PO Box 2507. Waxahachie.TX 75168
Certitted Tester{pri�-tl�oe Standrid�f3 Certitieci Tester(si��nslture , �
Pinn Phonc# (214) 444-3194 Cert.Teste���o. BP0015823 1�ate 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
`�USE ONLY MANUFACTURER'S REPLACEiV1ENT PARTS
White-Gity Copy Yello�v-Custonlei•Copy Pink-Tester's Copy