2015_1023 1RRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assesnbly tested. :� si�ned and dated qriginal
must be submitted to the public water supplier for►-ecordkeeping p�n-poses:
BACKFLOW PRE�'�NTIOI�.4�SEMSLY TEST A�,`d����I�iTE?VA�CE REPORT �
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�70040
(Gustottler)
MAILING ADDRESS: 253 Gl�b Circle Dr Cot�ell TX 75019
CONTACT PERSON/PHONE: D ni 214- -0
LOCATION OF SERVICE: O p� nc�
The backflow prevention assembiy detailed belo��l�as been tested and maintained as required by
commission re�ulations and is certificd to be operatine�G�ithin acceptable��arameters.
�'YPE OF A�SE�g�LY
Reduced Pressure Principle Reduced Pressure Priucip(e-Detector
X Double Check Val��e Double Checl:-Detectoi-
PressurcVacuumBreaker 5pi11=Resistant Pressure Vacuum Breaker
Manufacturer _ /�vv��g t��Iodel Numbe� �C9C9,� Size�_
Located �t Serial l�Iumbcr �le�('��
Is the assembly installe in accordance with tnauufacttu-er recommendations and/or local codes'? UGS
T
Reduced Pressure Princi le t�ssemblv i Pressure Vacuum Breaker
Double Check Valve Assembly
1 st Check � Relief Valve Air Inlet Check Valve
nd Check
��� Held at�,�psid Held at�,�psid Opened at Opc��ed at He(d at
Initial Test Closed Tight✓ Clused Tight ✓ psid psici psid
Leaked Leaked Did not open I�id nat oj�en Leaked
Repairs/
Materials
Used
Held�t �sid Held at psid �
Test After � Opeuc-d at Opened�t Held at
Repair Closed Tight ; Closed Tight , ps�� p��� psid
Test gauge used: Make/Model Anolla 40-200-tk5u SN:_ 04142867
Date Tested for Accuracy_ _5/4/2015
Remarks_
The above is cer-tified to be true�t the time of testing.
Firm Na�ne Diamondback Fire Protection Finn Address PO Box 2507. Waxahachie.TX 75168
Certit7cd Testei-{'pr;�-t�oe Standridge Certitieti T'estei�(si�n�attn-e)��L��-E� .
Firm Phonc# (214)44�4-3194 Cert.Tester\o. BP0015823 Dace 10/23/2015
'•`TEST RECORDS MUST BE KEPT FOR AT LEaST TNREE 1'EARS
'�* USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy