2015_1023 1RRIGATION DOMESTIC FlREL1NE X
The followin� form must be completed for each assembly test�ci. � sitined and dated original
must be submitted to the public water supplier for recordkeeping pui-poses:
BACKFLOW PRE�'ENTIOI�'ASSEMSLY T�ST AI�`�1R:�I�TENr�NCE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Gub Circle Dr Coppell TX 75019
CONTACT PERSOi�1/PHONE: D ni 214- -
LOCATiON OF SERVICE: ,,,�,p
The backflow prevention assembly detailed belo���has been tested and maint�ined as required by
commission regulations and is certificd to be operating�vithin acceptable��arameters.
'f'�'PE OF r-�SSEl�I�I.I'
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Check Valve Double Checl;-Detector
PressureVacuiimBreaker Spi11=P.esistant Pressure Vacuum Breaker
Manufactui•er �Q,�,..�g �lodel Number 2Dbf� g Size t��
Located �t (ho�ro..o. Serial Numbcc (��03
v
Is the assembly installed in accordance�jith mauufacturer recommendations and/or loca( codes?
Reduced Pressure Princi te Asscmbhr Pressure Vacuum Breaker
Double Cl�eck Valve Assembly
i st Check � Relief Valve Air Inlet Check Valve
nd Check
�� Held at .lo sid Held at �.C�
�A, psi O�ened at Op�ned at Hcld at
Initi�l Test Closed Tight✓ Closed Ti�ht psid psid psi��
Leaked Leaked Did not open I�id not open Leaked
Repairs/
Materials
Used
Held at psid Hcld at psid
Test After Opcncd ut Upened at Held at
Repair Closed Tight : Closed Tight psid psid psid
Test gauge used: Mahe/Model oll0 40-200-tk5u SN: 04142867
Date Tested for Acctn-acy: 5/4/2015
Remarks:
The above is certified to be true�t the time of testin�.
Firm Name Diamondback Fire Protection Firn1 Add�•ess PO Box 2507, Waxahachie TX 75168
Ce,-titied Tester(p,-;r:t�Qe Stan ridae Certitied Tester(signatur
Firm Phonc#(214) 444-3194 Ccrt.Tester No. BP0015823 nate 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEaRS
��`USE ONLY MANUEACTURER'S REPLACEMENT PARTS
White-City Copy Yello���-Customer Copy Pink-Tester's Copy