2015_1023 IRRIGATION DOMESTIC r1RELINE X
The following form must be completed for each assei��bly test�d. A ;;igned and dated original
must be submitted to the public water supplier for recordkeeping p�ilposes:
BaC1{FLOW PREa'ENTION.4SSEMBLY TEST:Al�'�VI�I��TENANCE REPORT
NAME OF PVVS: CITY OF COPPELL PVvS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Coq�ell TX 75019
CONTACT PERSON/PHONE: ni 214-
LOCATION OF SERVICE: Ic'�1 T,nc�a��*
The backflow pre��ention assembly detailed belo��has been tested and maintained as requircd by
commission regulations and is certificd to be orerating within acceptablc��aram�tcrs.
T'�'PE OF�.SSEl1�d��.I'
Reduced Pressure Principle Reduced Pressure Princip(e-Detector
X Double Check Val��e Double Check-Iaetector
PressurcVacuumBreaker Spi11=P.esistant Pressure Vacuum Breaker
Manufacturer�y�g Yiodel Numbe� �;C�t� � Size b"
Located At � Serial Numhcc 1ln(�5 �
Is the assembly installe in accordance with mauufacturer recommendations andror local codes'?
Reduccd Pressure Princi le Assemblv Pressure Vacuum Breaker
Double Clieck Valve Assembly
Relief Val�=e Air Inlet Check Walve
1 st Check 2nd Check
P0� Held at�psid Held at ��psid Upencd at Opcned at Held at
Initial Test Closed-['ight✓ Closed Tight ✓ psid psid psid
Leaked ` Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psict H�ld at psid
Test After Opei�cd at Upened at Held at
Repair Closed Tight ' Closed Tight:: psid psid �sid
Test gauge used: Make/Model oll0 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified ta be true at the time of testinQ.
Fiin1 Name Diamondbadc Fire Proteetion Finn Address PO Box 2507,Waxahachie TX 75168
� Certiticd Tester(p�-�;rt�oe Standridge Certifieci Tester(sig�i�lture�
Finn Phone# (214) 444-3194 Cert.Tester�o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�*USE ONLY MANUF�CTURER'S REPLACEMENT PAE�TS
White-City Copy Yelio�v-Customer Copy Pink-Tester's Copy