2015_1023 IRRIGATION DOMESTIC r}RELINE X
The following form must be completed for each assembly tested. A signed and dated oribinal
must be submitted to the public wacer supplier for recordkeeping ptuposes:
BACKFLOW PI�E�'ENTION ASSEMSLY T�ST A14'�til.�I�iTEN�NCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Glub Circle Dr CoQpell TX 75019
CONTACT PERSOivT;PHONE: Denisa 214-930-0933
LOCATION OF SERVICE: ��oce t S,,.r�1�,ern,e
The backflow prevention assembly detailed belo��has been tested and maintained as required by
commission re�ulations and is certificd to be operating�vithin acceptablc�raz�lmeters.
T�'PE OF�SSEll�IBLI'
Redueed Pressure Principle Red«ced Pressiire Principle-Detector
X Double Check Val��e Double Checi;-Detector
PressureVacuumBreaker Spill=Resistant Pressure Vacuum Breaker
Manufactui•er �y�A�g �Ylodel Number_��C� Size ("
Located At �o.� Serial Number l�o l 15
Is the assembly installe m accordance with mauufact�u-er recommendations and/or local codes'?
Reduced Presst3rc Princi le Assembhr Pressure�%acuum Breaker
Double Check Valve Assembly
R�lief Valve Air Inlet Check Valve
1 st Check ?nd Check
�1�5 Held at z.Z psid Held�t ?.� psid Opened at Oprned at Hcld at
lnitial Test Closed Tight ✓ Clos�d Tight ✓ psid � psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at �asid
Test After Opeucd at i Upened at Held at
Repair Closed Tight ' Closed Tight- �S�d }���� �si�
Test gauge used: Make/Model Anollp 40-200-tk5u SN: 04142867
Date Tested for Accui•acy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Firm Name Diamondbaek Fire Protection Firnl Addcess PO Box 2507. Waxahachie TX 75168
� Certiticd Testcr(pr;r;t�oe Standridae Certitied Tester sig
( 2iattu-
Firm Phonc# (214) 4443194 Cert.Testcr No. BP0015823 Datc 10/23/2015
'T TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEaRS
�� USE ONLY MANUFAC7'URER'S REPLACEMENT PARTS
White-City Copy I'ello�v-Customer Copy Pink-Tester's Copy