2015_1023 lRRIGATION DOMESTIC FlRELWE X
The following form must be cornpleted for each assembly tested. A sigiled and ciated original
must be submitted to the public water supplier for recordkeepitlg pur�oses:
BACKFLOW PREVENTION ASSEMBLY'TEST A14'D 1���I�TEN�t�'CE REPORT
NAME OF PWS: CITY OF COPPELL P1A%S I.D. #0570040
(Ctistomer)
MAILING ADDRESS: 253 Club Circle Dr Coqpell TX 75019
CONTACT PERSON/PHONE: D ni 214- 3 -0
LOCATION OF SERVICE: /�7 f ,T,,, �ano�„ ,Q,r-�P
The backflow prevention assembly detailed below has been tested and maiirtained as required by
commission regulations and is certificd to be operating��ithin acceptable��ar�met�rs.
T'YPE OF�SSEIVTBLI'
Reduced Pressure Pri�lciple Reduced Pressure Priilcipfe-Detector
X Double Cl�eck Valve Double Checi:-Detector
Presst�reVacuumBreaker Spi]1=Resistant Pf•essure Vacuum Breaker
Manufactui•er f�v►,.�_g �lodel iVumber 2�e9 g Size 4"
Located !At Serial Numh�r l(n�l�eo
Is the asseri�bly installe in accordance wirh mauufacturei•recommendations and/or local codes'?
Reeiuced PressiEre Princi (e Assembhr i Pressure�%acut�m Breaker
Double Check Valve AssemUly
1 st Check � Relief Valve Air Inlet Cl�eck Valve
nd Check
�p.�, Held at�--� psid Held at �.'1 psid Orened at__ Opcncd at Hcid at
Initial Test C'losed Tight ✓ Closed Tight ✓ psid � psi�i �y��
Leaked Leaked Did not open I�id not open Leaked
Repairs/
Materials
Used
Held at �sid Held at psid
Test After Upcucd at ; ()pei3ed at Held�t
Repair Closed Tight Closed Tight psid psid psid
Test gauge used: Make/Model An9��a 40-200-tk5u SN: 04142867
Date Tested for Acctiracy: 5/4/2015
Remarks:
The above is cei-tified to be true at the time of testing.
Firm Name Diamondbadc Fire Proteetion Firni Address PO Box 2507. Waxahachie TX 75168
Gertificd Testei•(pi-:�-:t�oe Standridae Certified Teste2•(sigi�attire)
Pinn Phonc# (214) 444-3194 Cert.Testea-No. BP0015823 Date 10/23/2015
'�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE 1'EARS
w� USE ONLY MANUFACTURER'S REPLACEMENT FARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy