2015_1023 IRRIGATION DOMESTIC t=1RELINE X
The following form inust be completed for each assembly tested. A signed and dated ari�inal
must be submitted to the public��vater supplier for recordkeeping�urposes:
BACKFLOW PRE��'ENTiON ASSENIBLY TEST�1�rD l�l:�i�,'TE'VANCE REPORT
NAME OF PWS: CITY OF COPPELL P��S I.D. #0�70040
(Gustomer)
MAILING ADDRESS: 253 Club Circle Dr CoRpell TX 75019
CONTACT PERSON/PHONE: Denise 214-930-0933
LOCATION OF SERVICE: Ic��53 �,.d.p����
The backflow prevention assembly detailed belo«�has been tested and maintaii�ed as required by
commission regulations and is certiticd to be operating��•ithin acceptable i�ar�meters.
TYP�OF A�S�I�IBI.I�
Reduced Presstu•e Principte Reducec� Pressure Princip(e-Detector
X Double Clleck Valve Doubtz Check-Detector
PressureVacut«nBreaker Spill=Resistant Pressure Vacuum Breaker
Manufactui•er_ ��g �lodel Numbe�- ;�!L�C�� Size 1"
Located At Serial Number l5"�S(�,
Is the assembly installe �n accordance with rnanufacturer recommendations andior local codes?
Reduced Pressure Princi le Assemblv Pressure�'acuum Breaker
Double Check Valve AssemUly
Relief Val��e Air lnlet Check Valve
1 st Check 2nd Check
QOuSs Held at 1lo psid Held�t�.�I psid O�encd at Qrcned at Heid at
Initial Test Closed T'ibht ✓ Closed Tight � �sid psid �psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psict Held at psid
Test After Opeucd at f�pcued at Held at
Repair Closed Tight Closed Tight psid psid �sid
Test gauge used: Make/Model Ao�lla 40-200-tk5u SN:__ 94142867
Date Tested for Accuracy: 5/4/2015
Remarks_
The above is certified to be true at the ti�ne of testina.
Firm Na�ne Diamondbadc Fire Protection Firn� Address PO Box 2507. Waxahachie.TX 75168
Certit►ed T'ester(�a-;.r.t�oe Standridae Certitied Testei�(si`�r�ature
Finn Phone#(214)444-3194 Cert.Tester�;o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
��USE ONLY MANUFt�CTURER'S REPLACEMENT PAR�I'S
White-Gity Co�y Yelioiv-Customer Copy Pink-Tester's Copy