2015_1023 IRRIGATION DOMESTIC FIRELlfVE X
The following form must be completed for each assembly tested. A si�ned and dated original
must be submitted to the public water supplier for i-ecordkeeping piu-poses:
BACI{FLOW PREVENT10N,4SSEMBLY'k'ES'I'Al�`i�14A€�TENANCE REPORT
NAME OF PWS: CITY OF CQPPELL P�%S I.D. #0�70040
� (Customer) �
MAIL[NG ADDRESS: 253 Club Circle Dr Coppell TX 75019
COI�TACT PERSON,PHONE: D ni 214- 3 - 9
LOCATION OF SERVICE: /D�// �',,,at,e��c��
The backflow prevention assembly detailed belo��has been tested and maintained as required by
commission re�ulations and is certificd to be operating�,vithin acceptable��arameters.
�'YPE OF ASSEI�IBLI'
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Cl�eck Valve Doubie Check-Detector
PressurcVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer �,�,� ��Iodel Numbe�- �Q�`�`Uc`�� SiZ� �''
LUcated f�t _Serial Nuu�hec l�olC9e�
Is t11e asseinbly installe in accordance with mamifacturer recommendations and/or local codes'?
Reduccd Pressure Princi le Assembh1 Pressure Vacuum Breakec
Double Clieck Valve Assetnbly
Relief Valve Air Inlet Check Va(ve
1 st Check 2nd Check
i695 Held at�,�psid Held at �.`'� psid Opel�cd at__ Op�ned at Hcld at
InitialTest ClosedTight✓ ClosedTight � psid psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Hcld at psid Ncld at psid
Test After Opcncd at Upened at Held at
Repair Closed Tight ± Closed Tight psid psid psid
Test gauge used: Make/Model����0 40-200-tk5u SN: 04142867
Date Tested for Accw•acy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Fii7n Name Diamondback Fire Protection Firni Address_ PO Box 2507. Waxahachie TX 75168
Gertified T'ester(pr;rt�oe Standridge Certitied Tester(si���atur
Firm Phonc#(214)444-3194 Cert.Testei•;�o. BP0015823 Date 10/23/2015
'�TEST RECORDS iVIUST BE KEPT FOR AT LEAST THREE YEARS
�*USE ONLY MANUFACTURER'S REPLACEA�ENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy