2015_1023 IRRIGATION DOMESTIC
�=1RELlNE X
The following form must be completed for each assembly tested. A si�ned and dated oribinal
must be submitted to the public water supplier for recordkeeping purposes:
B�CI�CFLOW PREVENTION ASSEMBLY'TES'��Nd��Vi���Ii�T�N��CE REPORT
NAME OF PWS: GITY OF CQPPELL PVvS I.D. #4�700�0
(Ctistomer) �
MAILING ADDRESS: 253 Club Circle Dr CoRpell TX 75019
CONTACT PERSON/PHONE: ni 214- -0
LOCATION OF SERVICE: Ih'�-� �T„�� ,,, ,�,.,c
The backflow prevention assembly detailed below has been tested and maintained as required by
commission regulations and is certiticd to be operating�vithin accept�blr f�arameters.
'I'�'PE OF ASSE1�i�I.Y
Reduced Pressure Principle Reduced Pressure Princip(e-Detector
XDoubleCheckValve Doubl�, C11eck-Detector
PressureVacuti�nBreaker Spi1l=Resistant Pi•essure Vactium Breaker
Manufacturer �„�,�a �lodel Numbe�- ,��8 Size `�_
Located At _Serial Niimher � �925
Is the assembly instalte in accordance with mauufacturer recommendations and/or local codes?
Reduced Pressure Princi le Assembhr Pressure�'acuum t�reaker
Double Check Valve Assembly
I st Check � Relief Valve Air Inlet Check Valve
nd Check
��S Held at �`� psid Held at��psid Orencd at__ Opcncd at Held at
Initial T�st Closed T'ight ✓ C1o�edTight �/ psid psid psi��
Leaked Leaked Did not open Did not ol�en Leaked
Repairs/
Materials
Used
Held at psicl Hcld�t psid
Tes[After �pened at Opened at Held at
Repaii• Gosed Tight i Closed Tight ps�d ps�� psid
Test gauge used: Make/Model oll0 40-200-tk5u SN: 04.142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testing.
Firm Name Diamondback Fire Protection Finn Address PO Box 2507. Waxahachie TX 75168
Certitied Tester(pr;�-t�oe Standridae Certitied Tester{si�`nattire) �
Firm Phoi�c#(214)444-3194 Cert.Testcr;�fo. BP0015823 Drtte 10/23/2015
#TEST RECORDS iVIUST BE KEPT FOR AT LEAST THREE YEARS
�*USE ONLY MANUFACTURFR'S REPLACEI�EI�T PARTS
White-City Copy Yello�v-Customer Co�y Pink-Tester's Copy