2015_1023 IRRIGATfON DOMESTIC F1RELlNE X
The follo�ving fonn must be conlpleted for each asseinhl_y teste�i. A signed and dated origi��al
must be subinitted to the pt�blic watei-supplier for recordkeeping ptn-p�ses:
SACKFLOW PRE\'ENTION ASSEMBL�'TEST r�ND��iAI1'�'�'ENA�CE 62EPORT
NAME OF PWS: CITY OF COPPELL Pw'S I.D. # 0�70040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Co�pell TX 75019
CONTACT PERSON/PHONE: Denise 214930-0933
LOCATION OF SERVICE: ,2,5�4���, �
The backflow prevention asscmbly detailed belo��-has been tested and maintained as required by
commission regulations 1nd is certitied to be operating�vithin acceptahle par�ui�eters.
'FYPE OF�SS�N�BL.�
: Reduced Pressure Principle Reduceci Pressure Piinciple-Detector
X Double Check Valve Double C'heck-Detector
PressureVacuuinBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer__ ��� Nlodel Number ,�C9Opg Size /"
Located At V�tQe�.C�� Serittl Number�l�,9�
Is the assembly installed in accordance u;ith manufactiu•er recammendations and%or local codes'?
Reduced Pressurc Princi�le Assemblv Pressure Vacuum Breaker
Double Check Valve Assembly
1 st Check � Relief Valve Air Inlet Check Vaive
nd Chcck
�� � Held at ��psid Held at psid Opened at_� Opci�ed at Held at
Initial Test Closcd Tight Closcd Tight psid psicl ��yi�{
Leaked ' Leakeci Did not open Did not oi�en Leaked
Repairs/
Materials
Used I
Hcld at psid Hcla at psid
Test After Opcncd at Upcned at HeJd at
Repair Closed Tight ! Closed T'i�ht �Sid ����� psi�
Test gau�e used: Make/Modei oll0 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Reinarks:
The above is certified to be true ak the time of testin�.
Firnl Na�ne Diamondbadc Fire Protection Firnl Address PO Box 2507. Waxahachie TX 75168
Certified Testcr(pr:,:t�oe Standridge Certitied Tcster(signa[ure
Firm Phone#_(214)4�4�4-3194 Ccirt.Tester:�o. BP0015823 _Uate 10/23/2015
'�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE 1'EARS
*� USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy 1'elloi��-C�istomer Copy Pink-Tester's Copy