2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assembly tesced. A signed and dated orijinal
must be submitted to the public water supplier for recordkeeping pur�oses:
BACKFLOW PRE�TENTION.4SSEMSLY TEST AND 1��I�TENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�700�0
(Customer)
MAILING ADDRESS: _ 253 Club Circle Dr Coppell TX 75019
C0�ITACT PERSON/PHONE:_penise 214-930-0933
LOCATION OF SERVICE:��,33 T„ �c��, �,on�
The backflow pi•evention assembiy detailed belo«�has been tested and maintained as required by
commission regulations and is ccrtified to be operating�i�ithin acctptable�r.irametcrs.
T'YPE OF�SSEi�I�L,Y
Reduced Pressure Principle Reduced Pressure Princip(e-Detector
X Double Cl�eck Valve Double Checl:-Detector
PressurcVacuumBreaker Spi1l=Resistant Aressure Vacuum Breaker
Manufacturer �w�q�� Nlodel Numbei• 2OC�G9$ Size ��_
Located At _S�rial 1'�Iunlher_ ��(`�$"(�
Is tlie assembly installe in accordance with tnauufacturer recommendations and�or local codes'?
Reduced Pressure Princi le Assemblv Pressure��acuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
l st Check 2nd Check
� Held at Z•o psid Held at �•Z psid Opencd at__ Oprned at Hcld at
Initial Test Closed Tight✓ Clused Tight ✓ psid psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at � psid Held at psid
Test After Opene�d at Op�»ed at Neld at
Repair ClosedTight ClosedTight psid psid �sid
Test gauge used: Make/Model_�p�q 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testinm.
Firm Naine Diamondback Fire Protection Finn Address PO Box 2507.Waxahachie TX 75168
Certificd Tester(pr��-:t���ndridge Certitied Tester(si;�nattire)
Finn Phonc# (214) 444-3194 Cert.Teste�-:�o. BP0015823 Date 10/23/2015
�`TEST RECORDS MUST BE KEPT FQR AT LEAST THREE YEARS
�* USE ONLY MANUFACTURER'S REPLACEMENT PARTS
Whire-City Copy Yello�v-Customer Copy Pink-Testei-'s Copy