2015_1023 1RRIGATION DOMESTIC FlRELINE X
� The following farm must be completed for eacll assembly test�d. A si�ned ��nd dated original
must be submitted to the public water supplier for recordkeeping purposes:
BACICFLOW PRE�'EIVTION,�SSEMBL�'TEST fl1�`D�VIAI�aTE'VANCE REPORT
NAME OF PWS: CITY OF COPPELL P�S I.D. #0�700�0
(Gustomer) � �
MAILING ADDRESS: 253 Glub Circle Dr Co�pell TX 75019
CONTACT PERSON/PHONE: Denise 214-930-0933
LOCATION OF SERVICE: �
The backflow prevention assembly detailed belo��r � been tested �nd maintained as required by
commission regulations and is certificd to be operating���ithin acceptablc�,arameters.
'�'�'PE OF A�SEI���LIT
Reduced Presst�re Principle Reducec� Pressure Princip[e-Detector
X Double Cl�eck Valve Doiible C1iec1:-Detector
PressurcVacuumBreaker Spi1l=Resistant Fressure Vacuum Breaker
Manufactui•er__�v,�.,�g t�lodel Number :��0� Size 1"
Located At C�a..e�0.o.� Serial Number pOS'23
Is the assen�bly iustalled in accordance with mauufacturer recommendations ai3d/or local codes'?
Reduced Pressure Princi �e Assemblv Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
'C� Held at�.y psid Held at 1.Z psid Opencd�it__ Orrned at Held at
� Initial Test Closed Tight ✓ Closed Tight ✓ psici p,��� ��s��{
Leaked : Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at }�sid Held at psid �
Test After �pencd at Opened�t Held at
Repair Closed Tight Closed Tight �S�d ps�� p5id
Test gauge used: Make/Model oll0 40-200-tk5u SN: 0q.142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin�.
Firm Nan1c Diamondbadc Fire Protection Firnl Address_ PO Box 2507. Waxahachie TX 75168
Certificd Testcr(p�-��s-�t�oe Standridae Certified Testei•(si����iture}
Firm Phone# (214) 444-3194 Cert.Testcr�o. BP0015823_ Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�* USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy �'ello�v-Customer Copy Pink-Tester's Copy