2015_1023 1RRIGATION DOMESTIC Fl�?ELINE X
The following form must be completed for each assembly tesled. A si�ned and ciated ori�inal
must be submitted to the public water supplier for recordkeeping�in-poses:
Bf1CKFLOW PRE�'ENTION.4SSEMBLY TE5'�'.�N�VI�A��TEN�lNCE REPORT
NAME OF PWS: CITY OF COPPELL P�tiS I.D. #0570040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Coppell TX 75019
CONTACT PERSOlV'/PHONE: i 214- -0
LOCATION OF SERVICE: 1��� =��o��,,�h�p
The backflow prevention assembly detailed belo«�has been tested and maintained as required by
commission regulations and is certificd to be operating�ti°ithin accept�ble�arameters.
'�'�'PE OF ASSEII�I���
Reduced Pressure Principle Red«ced Pressure Principle-Detector
XDoubleCheckVal�•e Double Check-I�etector
PressurcVacutimBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer Qy,,,�� vlodel Number 2L�plp, Size�_
Located f1t Serial Nu►nber ��,�� �
Is the assembly installe n accordance with znanufacturer recoi��mendatioiis and/or local codes'?
Reduced Fressure Princi le Ass�mblv Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
�(ygs Held at��psid Held at 1 .2 psid Orencd at Opcned at Hcid at
Initial Test Closed Tight✓ Closc;d Tighi ✓ psid psid � psid
Leaked Leaked Did not open 1�id not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test After Opea�cd at Opened at Held at
Repair Closed Tight ' Closed Tight , �S�d ps�� psid
Test gauge used: Make/Model�,nollo 40-200-tk5u SN:_ 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is cer-tified to be tr�ie at the time of testin¢.
Firm Naine Diamondbadc Fire Protection Finn Address PO Box 2507,Waxahachie.TX 75168
Certit7ed Tester(p�-i nt�oe Standridge Certifieci Tester(si��nature
Firm Phone# (214) 444-3194 Cci�t.Testcr No. BP0015823 Dace 10l23/2015
X TEST RECORDS iVIUST BE KEPT FOR AT LEAST THREE 1'EARS
*�USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy �'ellow-Customer Copy Pink-Tester's Copy