2015_1023 IRRIGATION DOMESTIC FIitELINE X
The following form must be completed for each assembly tesl�d. A ;i�nec� and dated oribinal
must be subinitted to the public�vater supplier for recordkeeping pur�oses:
BACKFLOW PREVENTION ASSEMSLY TEST A�,'�VIAI�iTENA?�CE REPORT
NAME OF PWS: GITY OF COPPELL PVJS I.D. #Q�70040
(Customer) � � �
MAILING ADDRESS: _25�Club Circte Dr Cot�ell TX 75019
GONTACT PERSON/PHONE: i 214- -0 3
LOCATION OF SERVICE:� ,��,�
The backflow prevention assembiy detailed belou�has been tested and maintained as required by
commission regulations and is certificd to be operating within acceptable p�ramete-rs.
� �r�rPE oF�ss��i�L� �
Reduced Pressure Principle Reduced Pressure Princi}�le-Detector
X Double Check Valve Doubte C'heci:-Detector
PressureVacuumBreaker Spi1l=Rzsistant Pressure Vacuum Breaker
Manufacturer��,,"� iYlodel Number 2pt�.� Size ►�"
Located At �e�.� �, Serial Numher 1l�(9�
Is t11e assembly instalted in accoi•dance v��itl�cnauufacturer recommendatioils ancL'or local codes'? U�S
Reduced Pressure Princi le t�ssembhr Pressure Vacuum Breaker
Double Check Valve AssemUly
Relief Valve Air Inlet Check Vaive
1 st Check 2nd Check
��l Held at'�—psid Held at p�id Opencd at__ OPr�7cd at Hcld at
Inrt�al Test Closed T'ight Clused Ti�ht psid � psick �psid
Leaked✓ Leaked Did not open Dici not open Leaked
Repairs/
Materials
Used
Held at Usid Neld at psid
Test After � Opeucd at Opened at Held at
Repair Closed Tight Closed Tight psid E�sid psid
Test gauge used: Make/Model Anollo 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks_
The above is certified to be true at the time of testin_.
Firm Name Diamondback Fire Protection Finn Address__PO Box 2507, Waxahachie,TX 75168
Cec•titicd Tester(p�:nt�oe Standridge Certitieci Testei�(si��nattu-e} � �
Firm Phonc# (214)444-3194 Ccrt.Testcr No. BP0015823 [)ate 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
T'� USE ONLY MANUFACTURER'S REPLACEiV1ENT PARTS
White-City Copy �'ello�v-Customei•�'opy Pink-Tester's Copy