2015_1023 IRRIGATION DOMESTIC
FlRELINE X
The follotiving form mtist be completed for each assemhiv tcsteci. A signcd and dated origival
must be subinitted to the ptiblic watei-supplier for recordkeeping puiposes:
BACKFLOW PRE�'ENTION A�SEMBLY'TEST AN�M1�I,�,��jTE?�ANC'E REPORT
NAME OF PWS: CIT'Y OF COPPELL PWS I.D. #05700�0
(Custome►•)
MAILING ADDRESS: 253 Club Circle Dr Cot�ell TX 75019
CONTACT PERS0�1/PHONE:Qenise 214-930-0933
LOCATION OF SERVICE:
The backflow prevention asscmbly detailed belo�v as Ueen tested and maintained as required by
con�mission regulations and is certifiieci to be operating�t=ithin acceptable��arameters.
T'YPE OF�iSS�1�IBLY
Reduced Fressure Principle Reducecl Pressure Principle-Detector
X Double Check Valve Double C'hecl:-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufachii-er�w.�tS Nlodel Number_ �90Ch g Size I"
Located �'1t a,r Serial Nunlbcr �j�� 3
Is the assembly i�istalled i accordance witll manufacturer recommeildatious and%or local codes'?
Re�uced Pressure Princi le Assembit Pressure��acuum Breaker
Double Check Valve Assembly
l st Check � Relief Vah�e Air Inlet Check Vaive
nd Check
PO�� Held at Z.�psid Held at Z..Z psicl Opened at___ Opcned at Held at
lnitial Test Closcd Tight✓ Cluscd Tigh[ ✓ }�sid psid 1�51�{
Leaked Leaked Did not o�en Did not open Leaked
Repairs/
Materials i
Used
Hcld at psid Hcl�l at nsid
Test After Opencd at___ Opcned at Held at
Repair Closed Tight : Closed Tight .. psid psid E�s��]
Test gau�e t►secl: Make/Modei oll0 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testinQ.
Firm Name Diamondbaek Fire Protection Firnl Address PO Box 2507, Waxahaehie TX 75168
Certified Tester(rri�:t�oe Standridae Certified Tcster(Si�,nati�i-e
Firm Phone# (214)4443194 C�rt.Testei�No. BP0015823 Date 10/23/2015
'�`TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�'* USE ONLY MANUE'ACTURER'S REPLACEMENT PARTS
White-City Copy Yello«�-Customer Copy Pink-Tester's Copy