2015_1023 IRRIGATION DOMESTIC N?RELfNE X
The following form must be completed for eac11 assembly tested. A si�ncd and dated oribinal
must be submitted to the public watei�supplier for recordkee�ing pur�oses
BACICFLOW PREVENTIOI�'.4SSEMBLY'`TEST A14`D V1.�I�iTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�70040
(Customei•)
MAILING ADDRESS: __253 Club Circle Dr Coppell TX 75019
GONTACT PERSQivT;PHOI�IE: D i 214- -0
LOCATION OF SERVICE: I�Xl2 1„� ,�n�o.., C�
The backflow prevention assembly detailed belo��has been tested and maintained as required by
commisslon regulations and is certiticd to be operating�i�ithin acceptabic��arametcrs.
T'YPE OF ASSEI�IB�,�'
Reduced Pressw•e Principle Redt�ce� Pressure Principle-Detector
X Double Cl�eck Valve Double Chc:ck-Detector
: PressurcVacuumBreaker Spi]1=Resistant Pressure Vact►um Breaker
Manufacturer�rn4 g Vlodel Numbe� ,�pt�8 Size l"
Loeated At�p.e et.� _Serial Nun�ber 1 lQ(�$Z
Is the assembly installed in accordance with manufacturer recommendations and/or local codes'? f
Reduced Pressure Princi le Assembl�� Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
YOi.� Held at�.�psid Helcl at I_$ psid Opencd�rt__ Opcned at Heid at
Initial Test Closed Tigltt ✓ Closed Tight ✓ �sid psi�l psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Heid at psid Hcld at psid
Test After Openc�d at Opened at Held at
Repair ClosedTight ' ClosedTight �S�d ps�� psid
Test gauge used: Make/Modcl 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 testing.
Fi�-�n Nan1e Diamondbadc Fire Protection Firn� Address PO Box 2507. Waxahachie TX 75168
Certiticd Testcr{rr;nt�oe Standridge Certifieci Tester(si`�nat«rc)
Firin Phonc#(214)4�44-3194 C�i�t.Tester No. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�*USE ONLY MANUFACT[1RER`S REPLACEA�ET�iT PART'S
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy