2015_1023 IRRIGATION DOMESTIC t=!RELINE X
The following form inust be completed for each assembly tested. A signed and ciated ori�inal
must be sub�nitted to the public watei•supplier for recordkeeping purposes:
BACI{FLOW P1�EVENTION.4SSEMBLY'TEST AI�'D 14Ai�i�'ENANCE REPORT
NAME OF PWS: CITY OF CQPPELL PWS LD. #0�70040
(Customer) � � �
MA1LlNG ADDRESS: 253 Club Circie Dr CoAr�ell TX 75019
CONTACT PERSON/PHOIVE: D i 214 3
LOCATION OF SERVICE: IE7fe�j � ,,,�
�
The backflow prevention assembly detailed belo«�has been tested and maintained as required by
commission re�ulations and is ccrtificd to be operating�vithin acceptable i�arameters.
'�'YPE OF r�i�SEIi�IBL�'
Reduced Pressure Principle Reduced Pressure Piinciple-Detector
X Double Check Vaive Double Cliecl:-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufachu-er�,�� Nlodel Number 2L`•bOB Size l`�
Located f1t Serial Numbec �S�-OZ
Is the assei��bly instalte in accordance with mamifacturer recommeildations anc�`or local codes'? �LS
Reciuced Pressure Princi le AssembhT , Pressure Vacuum Breaker
Double Check Valve Assembly •
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
i� Held at 1.2 Psid Held at 1�psid Onencd�it__ O�ened at F{cld at
Initial Test Closed T'ight ✓ Closed Tight ,� psid psid psid
Leaked Leaked Did not open I�id not opcn Leaked
Repairs/
Materials
Used
Held at psic! Hcld at psid
Test After Opcncd at � Upcnecl at Held at
Repair Closed Tight ' Closed Tight . psid psid psid
Test gauge used: Make/Model Mollo 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Finn Name Diamondbadc Fire Protection Finn Address PO Box 2507, Waxahachie TX 75168
Certiticd Tester(�r;nt�oe Standridge Certitied Tester(si��nature _
Firm Phone#(214) 444-3194 C�rt.Testc���o. BP0015823 I)acc 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACE��ENT PARTS
White-City Copy 1'ellozv-Customer Copy Pink-Tester's Copy