2015_1023 IRRIGATION DOMESTIC FIREUNE X
The follo�vin� form inust Ue co►npleted for each assembly tcsteci. A signed �lllll dated oriainal
cnust be submitted to the p�Rbiic�vater supplier for recordkeeping pui-poses:
BACKFLOW PRE�'ENTION ASSEMBLY TE�T Ai�'�i1�AII��T�'.�VAN�'E REPORT �
NAiV1E OF PWS: CI1'Y OF COPPELL A�'S I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Co�ell TX 75019
CONTACT PERSON/PHONE:_penise 214939-0933
LOCATION OF SERVICE: ' '{O
The backflow prevention asscmbly detailed belo��� as been tested and m�iiitained as required by
commission re�ulations and is certified to be operating�t�ithin acceptable p��ran�ete►s.
TYPE OF ASS��I�L,�
Reduced Pressure Princip(e Reduced Pressure Piinciple-Detector
X Double Check Valve Double Checic-Detector
PressureVacuumBreaker SpilI=Resistant Pressure Vacuum Breaker
Manufactui•er__ �vr.�,�g 1Ylodel Ntunber 2�OD8 Size I��
Located AT _('-�ic_�._se,d� Se►-ial Numbei'_(�p'�le+{
Is the assembly installed in accordance with mauufacturer recommendations and�`or local codes'? v�
Reduced Pressure Princi�le Assembh Press�rre`'acuum Breaker
Double Check Valve Assembiy
]st Check � Relief Vah,e Air Inlet Check Vaive
nd Check
�� Held at e`Z-2 psid Held at 2�psid Ol�cned at_____ Opencd at Neld at
lnitial Test Closcd Tight✓ Closcd Ti�.;ht ✓ psid psi�l ��y��{
Leaked ' Leaked id not open Did not open Lcaked
Repairs/
Materials {
Used {
Hcld at psid Hela at psid
Test After Opuned at (�pened at Held at
Repair ClosedTight i ClosedTi�ht : psid psid psid
Test gauge used: Make/Model�oll0 40-200-tk5u SN: 04142867
Date Tested foc Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testinQ.
Firn1 Name Diamondback Fire Protection Finn Address_PO Box 2507. Waxahachie TX 75168
Certitied Testei-(pi-��t�oe Standri ae Gertified Tcster(si��natur
Firm Phone#_(214)4�4-3194 Ccrt.Testei�Nt�. Bp0015823 I)ate 10/23/2015
'�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PART'S
White-City Copy Yello«�-Customer Copy Pink-Tester's Copy