2015_1023 IRRIGATION DOMESTIC F1RELiNE X
The following form must be completed for each assembly tested. A signed and dated original
must be subinitted to the�ublic watei�supplier for recordkeeping purposes:
BACI{FLOW PRE�'ENTION.4SSE1�9BLY TEST Al�'D 1�i1�I�iTENANCE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. #0�70040
(Ctistomer) �
MAILING ADDRESS: __�5�Club Circle Dr Co��ell TX 75019
CONTACT PERSON/PHONE: ni 214- 9
LOCATION OFSERVICE: I�ca�S T�no�, �her
The backflow prevention assembiy detailed belo«�has been tested and maint�ined as required by
commission regulations and is certificd to be operating�vithin acceptablc��ara��lecers.
'�'I'PE OF ASSEIl�I�I,I'
Reduced Pressiire Principle Reduced Pressure P�iuciple-Detector
X Double Cl�eck Valve Double Chec}:-Detector
PressureVacutunBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer �,,s,,� tYiodel Number 2�R Size ��` _
Located f�t �t�.�e�q�. Serial Numbcc l5��
Is the assembly installed in accordance with mauufacti.u-er recommendations and/or local codes'?
Reduced Pressure Princi le/�ssemblv Pressure S%acuum Breaker
Double Check Valve Assembly
Relief Val��e Air Inlet Check Valve
i st Check 2nd Check
�0�`� Held at �,� psid Held at�psid Onened at Optncd at � Hcld at
Initial Test Closed Tight✓ Closed Tight � psid psid psid
Leaked Leaked Did not open Did nat open Leaked
Repairs/
Materials
Used
Held at psid Neld at psid
Test After Opcncd at Opened at Held at
Repair Gosed Tight : Closed Tight psid psid psid
Test gaug�used: Make/Model Anollp 40-200-tk5u SN: 04142867
Date Tested for Acctiracy: 5/4/2015
Remarks:
The above is certified to be tr�ie at the time of testin�.
Finn Nainc Diamondbadc Fire Protection Firnl Address PO Box 2507. Waxahachie TX 75168
Certified Tester{pr�;s-t�ae Standridae C'ertified Testei•(sis���attire
Firm Phonc# (214)444-3194 C�rt.Testei-;�o. BP0015823 Date 10/23/2015
'�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE 1'EARS
�� USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy