2015_1023 IRRIGATION DOMESTIC FIRELINE X
The follo�ving form must be completed for each assemblv tested. A signcd and dated original
must be subinitted to the public water supplier for recordkeeping purposes:
SACKFLOW PRE1'ENTION A�SEMBLY TE�T��1�1�3 i7A[�;T�NA!�'CE REPORT
NAME OF PWS: CIT'Y OF COPPELL PW'S LD. # 0�70fl40
(Guston�er)
MAILING ADDRESS: 25�Club Circle Dr Co�p�ll TX 75019
CONTACT PERSON!PHONE: Denise 214-930-0933
LOCATION OF SERVICE: ��.J�y L,b ��„
The backflow prevention assembly detailed belo«�has been tested and maintained as required by
commission regt�lations and is certified to be operatin�«�ithin acceptable p��ran�etcr�.
T'YPE OF ASSENIBLY
Reduced Pressure Principle Reducecl Pressure Piinciple-Detector
X Double Check Valve Double C'heci;-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
iVIanufacturer�y�.�.Q,� Modet N�imber �2C�� Size (A
Located At � 5eiial Number �p'�'}-�'
Is tlle assembly installe in accordance v��ith manufacturer i•ecommendations and.�`or local codes'? VeS
Reduced Pressurc Arinci�le Assembl�� Pressure��acuiim Breaker
Double Check Valve Assembly
1 st Check � Relief Valve Air Inlet Check Valve
nd Check
Qp,.� Held at `Z_b psici Held at � .'a psid Opcned at_____ Openeci at Hc(d at
Initill Test Closcd Tight✓ Closcd Tight ✓ psid psid �sid
Leaked Leaked Did not open Did not oi�en Leaked
Repairs/
Materials i
Used
Hcld at psid Held at psid
Test After Opc��cd at ' Opened at Held at
Repair Closed Tight ` Closed Tight psid psid psid
Test gauge usecl: Make/Model Aoollo 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is ceitified to be true at the time of testing.
Finn Name Diamondback Fire Protection Finn Address PO Box 2507. Waxahachie TX 75168
Certified Testcr(pr:�-=t)Joe Standridae Certified Tcster(si�,nattn�e) �
Firm Phonc# (214)444-3194 C'ert.Teste��Nc�. BP0015823 _llate 10/23/2015
'�TEST RECORDS IvIUST BE KEPT FOR A-I'LEAST THREE YEARS
�* USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello«�-Customer Copy Pink-Tester's Copy