2015_1023 IRRIGATION DOMESTIC FIRELINE X
The follo�ving fonn must be completed for each assemblv tcsteei. A signed a�1d dated oriainal
must be submitted to the ptiblic water supplier for recordkeeping puiposes:
BACKFLOW PRE�'ENT10N A�SEMBL�'TE�T AN���i�[�TT�NA?�CE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. #0570040
(Custoiner) �
MAILING ADDRESS: 253 Club Circle Dr CoRpell TX 75019
CONTACT PERSO�I.iPHONE: Denise 214-930-0933
LOCATION OF SERVICE: 2�IQ, L;1„ ��.,.
The backflow pre`�ention assembly detailed belo«�has been tested and maintained as required by
commission rewlations and is certitied to be operating�i�ithin accepfable paran�eters.
"3'YPE OF ASS�NI�I.�'
Reduced Pressure Principle Reducecl Pressure Principle-Detector
XDoubleCheckValve � Double �'1�ed:-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer A 1 Vfodel Number o2.0(('�O f� Size �____��_
—r1n�sQ�
Located At C, .�p� Serial Number_ (rj��'}(r,
Is the assetnbly installed4l accordance v�jith manufacturer i-econ�me�tdations and�`or local codes'?
Reduced Pressurc Princi�le Assembh Pressure Vacuum Breaker
Double Cl�eck Valve Assembly
Relief Vah�e Air Inlet Check Vaive
]st Check 2nd Check
P� Held a� �� psici Held ui��psid Ol�enzd at__ Qpcncd at Held at
lnitial Tesc Closcd Tight-� Closcd Tight '� psici psid ��sid
Leaked ' Leaked Did not open Did not open Leaked
Repairs/
Materials �
Used
Hcld at psid Helci at psid
Test After ppc��cd at Opene�l at Held at
Repair GlosedTight : ClosedTight ps;� psid psid
Test gauQe 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 titne of testiva. �
Finn Name Diamondback Fire Protection Finn Address PO Box 2507.Waxahachie TX 75168
Certified Testcr(pra�t1Joe St�ndridae Certif ed Tcster(si��nature
[.,�'
Firm Phone# (214)4443194 Ccrt.Te.ster 1ti. BP0015823 Date 10/ /2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�~�USE ONLY MANUF�CTURER'S REPLACEMENT PARTS
White-City Copy Yellot��-Customer Copy Pink-Tester's Copy