2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assembly tested. A si�ncd and dated ori�inal
must be submitted to the public water supplier for recordkeeping purposes: y
BACKFLOW PRE�'ENTION ASSEMSLY TE��'Alti'D V$�AI�R'TENANCE REPORT
NAME OF PWS: GITY OF COPPELL PVUS I.D. #Q�70040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Coquell TX 75019
CONTACT PERSOiv';PHONE: ni 214- -0 3
LOCATION OF SERVICE: /O/} T,,,al �,v ,-,c�,�
The backflow pre��ention assembly detailed belo��has been tested and maintained as required by
commission re�ulations and is certitied to be operating��ithin accepiablc��arametcrs.
TYPE OF ASS�1�g�LY
Reduced Pressure Principle Rediiced Pressure Principle-Detector
XDoubleCheck Val<<-e Doi�ble Check-Detector
:PressureVacuuinBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer��.�g l�•lodel Number 2�[9� Size 1��
Located At _Serial Number ���l 7 Z
Is thz assembly installe in accordance with main�facturei-recomtnendatioiis andior local codes'?
Reduced Pressurc Princi le Assembhr Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Vahfe Air Inlet Check Vatve
l st Cl�eck 2nd Check �
�d� Helcl at�psid Held at�,U psid O�enc�l tit (�pcned at � Hcld at
� Initial Test Closed Tight ✓ Closcd Tight ✓ ps��� psid ���sid
Leaked Leaked Did not open I�id not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opencd at Upened at Held at
Repair Closed Tight Closed Tight psid psid psid
Test gauge used: Make/Model Aoollo 40-200-tk5u SN: 04142867
Date Tested for Acct�racy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Fi�-�n Naine_Diamondbadc Fire Protection Finn Address PO Box 2507. Waxahachie.TX 75168
Certitled Tester(rr;�-:t�oe Standridg.e Certified Tester(si��nature
Firm Phonc# (214)444-3194 Cert.Testci'�o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEiVIENT PARTS
White-City Copy �'ello�v-Customer Copy Pink-Tester's Copy