2015_1023 IRRIGATION DOMEST�C 1=1RELINE X
The following form must be completed for each assembly tested. A �i�ned and dated oribinal
must be submitted to the public water supplier for recordkeeping purposes:
BACKFLOW PRE�JENTION ASSEMSLY'I'ES'�'Al�`D 14:�i�i�'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL PV�%S I.D. #0�70040
(Customer)
MA1L[NG ADDRESS: 253 Club Circle Dr CoRr�ell TX 75019
CONTACT PERSON;PHONE: Denise 214-930-0933
LOCAT30N OF SERVICE: 1D3R'5��,�n.�„�r��on�g
The backflow pre�rention assembly detailed below has been tested and inaintained as required by
commission regulatians and is certificd to be operating�G�ithin acceptablc��arametcrs.
7'YPE OF�S�EIl��I�LI'
Reduced Pressure Priilciple Reduceci Pressure Principle-Detector
X Double Check Val��e Double Check-Detector
PressurcVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer F�}v�.�.� Ylodel Numbe�-_ �ppc9� Size �"
Located At Szrial Number_ �(QC93$'
Is the asseinbly instal ed in accordance with manufacturer reco�nmendations and/or local codes? '�Pv
Reduced Presst�re Princi le Assemb)v Pressure Vacuum Breaker
Double Cl�eck Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�0�.�� Held at��psid Held�t 2.2 psid O�ei�ed at Opti�ed�u � Held at
Initial Test C'losed Tight� Clused Tight ✓ psid psic! ��y���
Leaked Leaked Did not opeil Did not open Leaked
Repairs/
Materials
Used
Hcld at psicl Hcld at ��sid
Test After Opencd a( Uper�ed at Held at
Repair Closed Tight ; Closed Tight . psid psid p5i�
Test gauge used: Make/Model__�p��o 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/M2015
Remarks:
The above is certified to be true at the time of testin,.
Firm Name Diamondbadc Fire Protection Finn Address PO Box 2507. Waxahachie TX 75168
Certified Tester(pr:�-:t�oe Standridge CertiYied Teste�•(signattire
Finn Phonc# (214) 444-3194 Cert.Testcr;�o. BP0015823 I)ace 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
M*USE ONLY MANUPACTURER'S REPLACE�IENT PARTS
White-City Copy Yellozv-Customer Copy Pink-Tester's Copy