2015_1023 IRRIGATION DOMESTIC FlRELINE X
The following form tnust be completed for each assembly testeci. A si�ned and ciat�d original
must be submitted to the public water supplier for recordkeeping purposes
BACFCFLOW PRE�'ENT10N ASSEMBLY TEST A14'D�:�I�TE'VANCE REPORT
NAME OF PWS: CITY OF COPPELL PV�%S I.D. #0�70040
(Gustomer) � �
MAILING ADDRESS: 253 Club Circle Dr. Copqell TX 75019
CONTACT PERSON/PHONE: Denise 214-930-0933
LOCATION OF SERVICE: lc�'S$ 1`�Q „���r,�
The backflow prevention asseinbly detailed below l�as been tested and maintaitled as required by
commission regulations and is ccrtificd to be operating��-ithin acceptablc��ai-ameters.
T�'PE OF�SS�1l�IBL�
Reduced Pressure Principle Reducec� Pressure Principle-Detector
X Double Check Va1�•e Do�►ble Check-Detecror
PressurcVacuumBreaker Spi1l=Resistant Pressure Vacu�m� Breaker
Manufactui•er Q,,,,.,,�,� t�lodel Number 2�� Size I�
Located At _Serial �Iunlber���
Is the asseit�bly instalte in accordance w�ith manufacturer recommendations and/or local codes'?
Reduced Pmssure Princi le Assembhr i Pressure Vacirum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
"�0�-� Held at��psid Held at��pJs'd Opened at Opri7ed at Held at
Initial Test Closed Tight ✓ CloseclTight✓ psid psi�l psid
Leaked Leaked Did not open I�id not ol�en Leaked
Repairs/
Materials
Used
Held at �sid Held at psici
Test After Opencd at Upened at Held at
Repair Closed Tight Closed Tight psid psid psid
Test Qauge used: Make/Model Aoollp 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time oFtestina.
Fii-�n Name Diamondback Fire Protection Firn� Address PO Box 2507,Waxahachie TX 75168
Certiticd Tester(��-:��t�oe Standridae Certitied Tester(signature
Finn Phone#_(214)444-3194 Cert.Tester No. BP0015823 Date 10/23/2015
"TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEAR5
'��`USE ONLY MANUFACTURER`S REPLACEA�ENT PARTS
White-City Copy Yelloiv-Customer Copy Pink-Tester's Copy