2015_1023 IRRIGATION DOMESTIC FlRELINE X
The following form must be completed for each assembly tested. A signed �nd dated original
must be submitted to the public water su�plier for recordkeeping pur�oses:
BACI{FLOW PREVENTION:�SSEMBLY TE��'A14'D 1�lAI�TE'VA�CE REPORT
NAME OF PWS: CITY OF COPPELL PVJS I.D. #0570040
(Customer)
MAILING ADDRE5S: 253 Club Circfe Dr CopQell TX 75019
CONTACT PERSON/PHONE:D ni 214-
LOCATION OF SERVICE: I174,5 S�e O,��n�
The backflow prevention assembly detailed belo«•has been tested and maintained as required by
commission regulations and is certified to be operating��-ithin acce}�tablc��a�-ameters.
TYPE OF��5E1V�l��,I'
Reduced Pressure Principie Red�icec� Pressure Principle-Detector
XDoubleCheckValve Double Cliecl:-Detector
PressurcVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufactui-er /1,,,,�,y �lodel Number "
a�� 8 s�Ze�_
Located f�t C--ie�,��Ct�. Serial Number �le�(2g�
Is tile assembly installed in accordance with manufacturer recommendations and/or local codes'? ue�5
Reduced Pressure Princi le Assembhr Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
!st Check 2nd Check
�� Helcl at�psid Held at�.(a psid Oneni;d at O��cned at Held at �
Initial Test Closed Tight Closcd Tight psid psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Hcld at psid
Test After Opencd at Upened at HeJd at
Repair Closed Tight :' Closed Tight psid psid psid
Test�auge used: Make/Mode}�pollo 40-200-tk5u SN: 04.142867
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
Certified Teste,-(pr:s-.t�oe Standrida� Certitied Tester(sis�natur
Finn Photic# (214)444-3194 Cert.Tcster�o. BP0015823 I)ate 10/23/2015
'�`TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�'��USE ONLY MANUFACTURER'S REPLACEYIENT PAftTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy