2015_1023 IRRIGATfON DOMESTIC �=1RELiNE X
The following form must be completed for eacl� assemhly testeci. A signcd �ind dated ariginal
must be submitted to the public��vater supplier for recordkeeping purposes:
BACI{FLOW PRE�'ENTION ASSEMSLY TES'I'AN�YI.aI�TE�VAtv'CE REPORT �
NAME OF PWS: GITY OF COPPELL PVvS I.D. #0�70040
(Gustomer)
Iv[AILING ADDRESS: 253 Club Circie Dr oppell TX 75019
COI�TACT PERSON/PHONE: Denise 214-930-0933
LOCATION OF SERVICE:
The backflow prevention assembly detailed belo��r has een tested aud maintained as required by
commission re�ulatians and is certificd to be operating within acccptable��aramete-rs.
'�'YPE OF�SSEI�IB�.�'
Reduced Pressure Principle Reduced Pressure P�7ncip(e-Detector
X Double Check Valve Double Check-Detector
PressurcVacutimBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer��g Ylodel Number ,2[ (� Size I"
Located E1t e d� Serial Numbec 1�-�1�
Is the asseinbly install�d in accordance with manufacturer recommendations andior local codes'?
Rcduced Pressure Princi le Assembhr Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
I st Check 2nd Check
�� Held at Z.� psid Held at 2.0 psid O�ened at Oprned at F-Ic(d at
Inikial Test Clased Tight✓ Closed Tight `� psid psid ps��
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
Used
Held at psid Held at psid
Test At�er Opeucd at Opened at Held at
Repair CJosed Tight Closed Tight �S�d ps�� psid
Test gauge t�sed: Make/Model Anollo 40-200-tk5u SN: 04142867
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 Firn1 Address PO Box 2507. Waxahachie TX 75168
Certiticd Testcr(��-i��t��Standridge Certitied Testei-(si��nat«re�
Firm Phonc#_(214) 444-3194 Ci:rt.Tester No. BP0015823 Date 10/23/2015
x TEST RECORDS iVIUST BE KEPT FOR AT LEAST THREE 1'EARS
*�USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Testel-'s Copy