2015_1023 1RR16ATION DOM�STIC FIRELINE X
The following form must be completed for each assembly testec�. :� signed and dated original
must be submitted to the public water supplier for recordkeeping p�n-poses:
BACKFLOW PRE�'ENT�ON ASSEMBLY TES�'.�1�'�1�flAI�iTE!VANCE REPORT
NAME OF PWS: GITY OF COPPELL P��S I.D. #0�70040
� � (Gustomer) �
MAILING ADDRESS: 253 Club Circle Dr Coppell TX 75019
CONTACT PERSOiv'/PHONE: ni 214 - 3
LOCATION OF SERVICE:__[Q��j r�.���,� ��,�
The backflow prevention assembly detailed below has been tested and maintained as required by
comrnission re�ulations and is certiticd to be operating�vithin accepi�ble t�ai•�metcrs.
7'YPE OF�SSEIl�IBLI'
Reduced Presstn-e Principte Reduced Presstire Princip(e-Detector
X Double Check Valve Dozible C'heck-Detector
PressureVacuumBreaker Spi1l=Resistant Pi•essure Vacuum Breaker
Manufactui•er__ ��g i��Iodel Numbe�- ZU[�C9 (3 Size Lu
Located At Serial Nun�her_ �lo�Zq
Is the assembly installed i accordance�jith znam2facturec recomn�endations and/or locat codes?
Reduced Pressure Princi le Assemblv Pressure�%acuum Breaker
Double Clieck Valve Assembly
Relief Val�je Air Inlet Check Valve
1 st Check 2nd Check
P� Held at,,lo psid Held at �.� psid Orened at Opcned at Hcld at
Initial Test Closed Tighi ✓ Cl�sed Tight ✓ psid � psi�l �p,i��
Leaked Leaked Did not open Did not apen Leaked
Repairs/
Materials
Used
Held at ��sid H�ld at psid
Test After Upcncd at �pencd at Held at
Repair Closed Tight ' Closed Tight ps�d ps�d �5}d
Test gauge used: Make/Mode1 Ilo 4Q-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin�.
Fii7n Namc Diamondback Fire Protection Firni Address PO Box 2507. Waxahachie TX 75168
Cerriticd Tester(prirt�oe Standridae Certifieci Testei�(sigiiati�re)
Finn Phonc#(214)444-3194 Ccrt.Testc��\o. BP0015823 [)ate 10/23/2015
`TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�* USE ONLY MANUFACTURER'S REPLACE�IENT'PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy