2015_1023 IRRIGATION DOMESTIC t=1RELINE X
The following form must be completed for each assemhly test�d. A sigi�ed and datc:d ori�inal
must be submitted to the public�vater supplier for recorclkeeping p��rposes:
BACICFLOW PRE��ENTION.4SSEMSLY TEST Ah'D 1�6:�I�iT�NANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. # 0�70040
(Customer) �
MAIL[NG ADDRESS: 253 Glub Gircle Dr Coppell TX 75019
COI�ITACT PERSON/PHONE:_penise 214-930-0933
LOCATION OF SERVICE_ �32 L.1rsQ }�
The backflow prevention assembly detailed below has been tested�nd mainrained as required by
commission regulations and is certificd to be operating�vithin acccptablc��aramecers.
'�'YPE OF��SE��BL�
Reduced Pressure Principle Reduced Pressui-e Principle-Detector
X Double Check Val��e Double Check-Detectar
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufactui•er__ �,,,,�Q� vlodel Number ?.Ca6c $ Size 1"
Located At Se►-ial Number pp(�p �
[s the assembly installe in accordance with manufacturei•recommendations and/or local codes'?
Reduccd Pressure Princi le Assembhr Pressure Vacuum Breaker
Double Clieck Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
1'°"" Held 1t�psid Held at l.� psid O�eil�d at Opened at Hcld at
Initial Test Closed Tight✓ Closed Tight ✓ psid p,��� ��y��{
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
�
Helci at �sid Held at psid � �
Test After Opeucd at Opened at Held at
Repair Closed Tight ' Closed Tight ps�d ps�� ps�d
Test gauge used: Make/Model_�p�p 40-200-tk5u SN: 04142867
Date Tested for Acctii•acy: 5/4/2015
Remarks:
The above is ceitified to be true at the time of testing.
Firm Namc Diamondback Fire Protection Firnl Address PO Box 2507. Waxahachie TX 75168
Certit7cd Testcr(pr;�-t�oe Standridge _Certitied Tester(sit�iattn-eX�
Firm Phonc# (214) 444-3194 Cetrt.Testcr No. BP0015823 _ Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE 1'�.ARS
�'* USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy