2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assembly tested. A signed and ciated original
must be submitted to the public water supplier foc•recordkeepit�g p�n-poses:
SACKFLOW PRE�'ENT10N.�SSEMSLY TEST A1�TD 1���I:�'TEN,�NCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #Q5700�0
(Gustomer)
MAILiNG ADDRESS: 253 Club Circle Dr Copqgll TX 75019
CONTACT PERSONIPHONE: D ni 214- - 9
LOCATI�N OF SERVICE:
The backflow prevention assembly detailed belo��� �as been tested and maintained as required Uy
commission regulations and is certificd to be operating���ithin acceptable�arameters.
'�'YPE OF ASSE1l�IBI,Y
Reduced Pressure Principle Reduced Pressure Principle-Detector
� X Double Clieck Va14�e ��Doubie Checl;-Detector �
PressureVacuumBreaker Spi]1=Resistant Pressure Vacuum Breaker
Manufacturer�,,,,�,�g �Iodel Numbe�- 2c�c�o S Size �"
Located At Ce� _Serial t�lumber L�l(�y
Is the assembly installed n accordance wirh mamifacturer recoinmeildations and/or local codes'? S
Reduced Pressure Princi le Asscmbhr i f'ressure\%acuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
I st Check 2nd Check
�� Held at '�' psid Held at psid Opened at Opened at Hcld at
Initial Test Glosed Tiy�ht � Closed Tight �sici ��si�l psid
Leaked v Leaked Did not open Did not open Leaked
Repa i rs/
Materials
Used
Held at psid Hcld at ��sid
Test After Openrd ut Upcned at Held at
Repair Closed Tight ' Closed Tight psid psid psid
Test gau�e used: Make/Model�o 40-200-tk5u SN: 04142867
Date Tested for Acctiracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testina.
Firm Name Diamondbaek Fire Protection Firnl Address PO Box 2507. Waxahachie.TX 75168
Certiticc3 Tester(rr;+�t�oe Standridae Certitied Tester(si��i�at�u�
Firm Phone#(214)444-3194 Cert.Testcr\a. BP0015823 I)ate 10/23/2015
'�TEST RECORDS iUIUST BE KEPT FOR AT LEAST THREE YEARS
�� USE ONLY MANUFACTURER`S REPLACE��ENT PART'S
White-City Copy I'ello�v-Customer Copy Pink-Tester's Copy