2015_1023 IRRIGATION DOMESTiC rIRELINE X
The following form must be completed for each assembly testeci. A signed and dated original
must be submitted to the public water supplier for recordkeeping pui-poses:
BACKFLOW PRE�'ENTION ASSEMBLY TEST A14`D��AI�iTE�iANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #Q570040
(Gustomer) � �
MAILING ADDRESS: 253 Club Circle Dr Connell TX 75019
CONTACT PERSOi�1/PHONE: i 214- 3 - 933
LOCATION OFSERVICE: �1��'�I'.,.�,.�Q ,,, �„�s
The backflow prevention assembly detailed below has been tested and maint�ined as required bY
commission re�ulatians and is certificd to be operating�vithin acceptaE�le��arameters.
'�'YPE OF A�SEI�I�I.Y
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Check Valve Doubie Check-Detector
PressureVacut�mBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacttii•et- _A�,,,.�� Nlodel Number ZOCSC� I3 Size '�_
Located E1t C�r-p�o..L Serial Numher �y(7$'�
Is the assembly installed in accordance with mauufactw-er recomiuendations and/or local codes'?
Recluced Pressure Princi le Assemblv Pressure Vacuum Breaker
Double Clieck Valve AssemUly
1 st Check � Relief Val�je Air Inlet Check Valve
nd Check
�� Held at �.� psid Held at �p;id O�encd at__ Oprned at Hcld at
Initi�lTcst ClosedTight�✓ ClosedTight psid psid ��sid
Leaked Leaked ✓ Did not open I�id nat open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Openid at Upened at Held at
Repair Closed Tight ' Closed Tight. ps+d E�sid psid
Test gauge used: Make/Model Anolla 40-200-tk5u SN: 04142867
Date Tested for Acctiracy: 5/4/2015
Remarks:
The above is cel-tified to be true at the ti�ne of testii�g.
Fi�7n Name Diamondbade Fire Protection Finn Address PO Box 2507. Waxahaehie TX 75168
Certitied Tester(ra-:nt�oe Standridge Certitied Tester(si��nati e
Finn Phonc# (214)444-3194 Cert.Tester No. BP0015823 Date 10/23/2015
�`TEST RECORDS iI�UST BE KEPT FOR AT LE�ST THREE YEARS
�'�USE ONLY MANUF.ACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Testei's Copy