2015_1023 IRRIGATION DOMESTIC fIRELlNE X
The following forin must be completed for each asscmbly tested. A signed and dated original
must be sub�nitted to the pt►blic��vater supplier for recordkeeping purposes:
$ACKFLOW PRE�'ENTION ASSEMSLY TES�'Al�'i�1�i1�I�TENANCE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. #0�70040
� (Customer) � �
MAILING ADDRESS: 253 Club Circle Dr. Co��ell TX 75019
CONTACT PERSON/PHONE: ni 21 - 3
LOCATiON OF SERVICE: I�ylo `r'�p��P
The backflow prevention asscmbly detailed belo«�has been tested and mai�rtained as required bY
com�nission regulations and is certified to be operating�ti�ithin acceptabie��ar�meters.
7'YPE OF ASSEI�I��.�'
Reduced Pressure Principle Reducec� Pressure Princip(e-Detector
X Double C1�eck Valve ��Double Clleck-Deteetor �
PressureVacutunBreaker Spi1�=Resistant Pressure Vacuum Breaker
Manufactui-er �� Nlodel Number t c�.Y�j(� Size �"
Located At ('-�o�c'q,o.e Serial Nunlbec ��Z�`L
Is the assembly installed in accordance with manufacturer recommendatioils and/or local codes'? vGS
Reduced Pressure Princi le Assembhr Pressure�%acuum Breaker
Double Cl�eck Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Clieck 2nd Check
�e�..�s Held at Z,� psid Htld at�_2p�id O��encd at_, Orrn�d at Hcld at
Initill Test Closed-['ight✓ Closed Tight ✓� psiei psi�! psid
Leaked ` Leaked Did not open Did uot open Leaked
Repairs/
Materials
Used
He(d at psid Held at psid
Test Atter Opencd ut � Opc��ed at Held at
Repair Closed Tight ' Closed Tight psid psid 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 testinQ.
Fiim Na�ne Diamondbadc Fire Proteetion Finn Address PO Box 2507. Waxahachie.TX 75168
Certitied Tester(pi-:rt�oe Standridae Certifieci Testei-(si�n��ture���
Finn Phoitc# (214)444-3194 C�rt.Testcr;�o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST Tl-�REE 1'EARS
�� USE O�LY MANUFACTURER'S REPLACEI��ENT PAf�TS
White-City Copy �ello«�-Customer Copy Pink-Tester's Copy