2015_1023 IRRIGATION DOMESTIC FlRELINE X
The following form must be completed for each assembly tesled. A si�ned �lt1C� dated ori�inal
must be submitted to the public��vater supplier for recordkeeping purposes:
BACKFLOW PRES'ENTION ASSEM19BLY'TES'�.�1�'I�1�9Ai�'TENAICE REPORT
NAME OF PWS: CITY OF CQPPELL PWS I.D. #0�70040
(Customer) � �
MAILING ADDRESS: 253 Club Circle Dr Coqnell TX 75019
CONTACT PERSON,PHONE: D ni e 214- -
LOCATION OF SERVICE: � �,r, P
The backflow prevention assembly detailed belo«�has been tested and maintained as requircd by
commission regulations and is certiticd to be operating��-ithin acceptablc t�arameters.
TI'PE OF�SSEIl�$I�LI'
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Check Val��e Double C11eck-Uetector
PressurcVacuu�nBreaker Spill=Resistant Pi•essure Vacuum Breaker
Manufacturer�g �lodel Numbe� `1.C�b� Size ��•
Located �t (a0.�o,�� _Seri�il Numbcr_ 1� S
�
Is the assembly installed in accordance with mauufacturer recon�mendations andror local codes'?
Reciuced Pressure Princi 1e Assemblv Pressure Vacuiim Breakei-
Double Check Valve Assembly
1 st Check � Relief Va1ve Air lnlet Check Valve
nd Check
�p�S Held at 2.0 psid Helcl at�_p;id ()ren�d�rt__ O�ci�ed at Held at
Initial Test Closed T'ight✓ Closcd Tight � psid psicl i�s��{
Leaked Leaked Did not open I�ici nat open Leaked
Repairs/
Materials
Used
Held at psid Held at ��sici
Test After Opeucd at Opeued at Held at
Repair Closed Tight ; Closed Tight: ps�d E�si� psid
Test�auge i►sed: Make/Mode1 Ilo 40-200-tk5u SN: 04142867
Date Tested for Acciu-acy: 5/4/2015
Remarks:
The above is certified to be true at the time of testina.
Firm Na�ne Diamondbaek Fire Proteetion Finn Address PO Box 2507, Waxahachie TX 75168
Certificd Tester(pr:r.t�oe Standridge Certified Tester(signature
Firm Phone#(214)444-3194 Ceirt_Testcr�!o. BP0015823 Date 10/23/2015
x TEST RECORDS MUST BE KEPT FOR AT LFAST THREE YEARS
T* USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy