2015_1023 IRRIGATION DOMESTIC
FIRELWE X
The follo�ving form must l�e completed for each assemblv testeci. A signed ilf1C� dated original
must be submitted to the public watei-supplier for recordkeeping purposes:
BACKFLOW PRE�'ENTpON ASSEMBL�'T'EST�1�'�iVIEtC�''P'�NA�CE f2EPORT
NAME OF PWS: CITY OF COPPELL PW'S I.D. #0570040
(Custonier)
MAILING ADDRESS: 253 Club Circle Dr Co�ell TX 75019
COIvrTACT PERSON/PHONE: Denise 21493Q-0933
LOCATfON OF SERVICE:_�ltl'.� ;�,,�r ,
The backflow pre��ention asscmbly detailed belo�� has been tested and m�iiitained as required by
commission regulations and is certiticd to be operating�i•ithin acceptable p��rameters.
Z'Y�E OF�SS�1i�gBL�
Reduced Pressuce Principle Reducecl Pressure Principle-Detector
XDoubleCheckValve Double Check-Detectar
: PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer__ �r,,,�� Model Number �R Size ��_
Located At�,�,r�p�� Serial Number (rj9945
Is the assen�bly installed in accordance v��ith manufacturer reco�nmeudatious andr'or local codes`?
Reduced Pressurc Princi�lc Assembl�- Pressure Vacuiim Breaker
Double Check Valve AssemUly
1 st Check � Relief Vah�e Air Inlet Check Vaive
nd Chcck
� Held�t��psid Held aT Z-� psid Open�,d at__� Opcned at Held at
Initial Test Closcd Tight ✓ Closcd Tight '� }�sid psid psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials �
Used
Hcld at psicl Hel�l at psic�
Test After Opcncd at ' Opened at Held at
Re�air Closed Tiaht ' Closed Tight psid psid psid
Test gauge used: Make/Modei oll0 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Reinarks:
The above is certified to be true at the time of testin,.
Firn�Na�ne Diamondback Fire Protection Firnl Address_ PO Box 2507. Waxahachie TX 75168
Certified Testcr(pr:�,�t)Joe Standridge Certitied Tcster(si��nat�n•e) �
Finn Phone#_(214)444-3194 Cert.Tester No. BP0015823 Date 10/23/2015
"TEST RECORDS ivIUST BE KEPT FOR AT LEAST THREE YEARS
�� USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy 1'ellozv-Customer Copy Pink-Tester's Copy