2015_1023 IRRIGATION DOMESTIC FlRELINE X
The following form must be completed for each assembl_y testLd. A ;i�ned and dated original
must be submitted to the public water supplier for recordkeeping pw-poses:
BACICFLOW FREVENTION.4SSEMBLY'TESTAI�'�1�AI�TENANCE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. # 0�70040
(Ciistomer)
MAILING ADDRESS: 253 Club Circie Dr Co�taell TX 75019
CONTACT PERSON/PHONE:D i 214- - 9
LOCATION OF SERVICE. 1[O.Sp T,,,�000 r+ ,p S�
The backflow prevention assembly detailed belo��has been tested and maintained as required by
commission regulations and is certificd to be operating within aceept�ble i�ar�m�cen.
'TYPE OF.�S�E1l�iBLY
Reduced Pressure Principle . Reducec� Pressure Principle-Detector
X Double Check Val��e Double Checic-I�etector
PressurcVacuumBreaker Spill=Resistant Pressure Vacuum Breaker
Manufacturer__/-��� iYlodel Number J�JC.�$ Size �`�
Located At _Serial Number (SL^9p
Is tlie assembly installe in accordance with mauufacttu-er recommendations arid%or local codes'? V�S
Reduced Pressi3re Princi le Assemb{v Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Vah�e Air Inlet Check Valve
1 st Check 2nd Check
��� Held at 1.Z psid Held at 1.Z psid O�e��ccl at Opci�ed at Hcld at
Initial Test Closed T'ight Clused Tight psid psid ps��j
Leaked Leaked Did not open L�id not open Leaked
Repairs/
Materials
Used
Held at psici Held at psid
Test After Opeucd at <)pened at Held at
Repair Closed Tight ± Closed Tight , �S�d ps�� psid
Test gauge used: Make/Model__�oll0 40-200-tk5� SN: 04.142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Firm Name Diamondbadc Fire Proteetion Firnl Address_ PO Box 2507 Waxahachie TX 75168
Certitied Test�r(p�-�;rt�p�Standridge Certifie�i Tester(si����itut �
Firm Phanc# (214)444-3194 Cert.Testcr\o. BP0015823 Date 10/23/2015
T TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�� USE ONLY MANUFACTURER`S REPLACEMENT PART'S
�h�hite-City Copy 1'ello�v-Customer Copy Pink-Tester's Copy