2015_1023 IRRIGATION DOMESTIC FlRELINE X
The following form inust be completed for each assembly testea. A si�ned and dated oribii�al
must be submitted to the public water supplier for recordkeeping p�u-�oses:
B�CKFLOW PRE�rENTION ASSEMBLY TEST�"�14'�Vfl1���TENA�CE REPORT
NAME OF PWS: CITY OF COPPELL Pu�S LD. #0�70040
(Customer)
UTAILING ADDRESS: 253 Club Circle Dr CoRpell TX 75019
CONTACT PERSOiv',PHONE:D ni 214 0
LOCATION OF SERVICE: /�9� `7' d P �,,��c�
The backflow prevention assembly detailed belo«�has been tested and maint�ined as required by
commission regulations and is certitied to be operating�t�ithin�iccept�ble��ai-ainetcrs.
�'YPE OF ASSEll�I�LY
� Reduced Pressure Prii�cipte Reduced Pressure P�iilcip[e-Detector
X Double Check Valve ���Double C:1�ec1:-Detector �
PressureVacuumBreaker Spi1l=Resistant Pressuce Vacuum Breaker
Manufactui•er K»titrS �Ylodel iVumbe� 2�$ Size l"
Located At C Serial Numb�r l lQ�\3
Is the assembly instalte in accordance witl�znauufacturer recommendations ancUor local codes'? U°�5
-�----
Reduced Pressure Princi le Asseinblv Pressure Vacuum Breakei-
Double Check Valve Assembly
Relief Vahje Air lnlet Check Valve
1 st Check 2nd Check
��S Held at�-lo psid Held at��p,id Opencd at_ Opci�ed at Hcld at
Initial Test Closed Tight✓ Closed Tight � ps��j psid �sid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held�tt psid Held at psid
Test At�er Opencd at Opeued at Held at
Repair Gosed Tight : Closed Tight , psid psid psid
Test gauge used: Make/Model Anollo 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin�.
Fi�,n Name Diamondback Fire Protection Firni Address PO Box 2507. Waxahachie.TX 75168
Certit7ed Testcr(�i-;�-t}�oe Standridae Certitied Testel•(si�niature�
Firm Pho��c#(214)444-3194 Cc:rt.Testcr Na. BP0015823 I)atc 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LE�ST THREE 1'EARS
"��USE ONLY MANUFACTURER'S REPLACEiV1ENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy