2015_1023 IRRIGATION DOMESTIC FIRELlNE X
The folloGving fonn inust be coinpleted for each assemblv testecl. A si�ned and dated original
must be submitted to the ptiblic water supplier for recordkeeping put-poses:
BACKFLOW PRE�'ENTION A�SEMBL�'TEST AND��l�ii�'T�':V�lNC'E REPORT
NAME OF PWS: CI?Y OF COPPELL PW'S I.D. #0570040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Cont�ell TX 75019
CONTACT PERSON/PHONE: Denise 214930-0933
LOCATION OF SERVICE: 5 �
The backflow pre��ention assembly detailed belo�- s been tested and m�intained as required by
commission re�ulations and is ce�-tified to be operatin��vitliin acceprab(e p�lran��ters.
'TYPE O�ASS�NI�LY
Reduced Pressure Principle Reducecl Presstu�e Principle-Detector
X Double Check Valve Double Gl�eck-Detector
PressureVacuumBreaker Spill=Resistant Pressure Vacuum Breaker
Manufacturer f-�w.�,,g Nlodel Number oZi9G`1C�� Size 1"
Located At C�o�e Serial Number_ /'-IC�ZS
Is the assembly installe zn accordance with man�ifactiu-er recomme�ldatious and/or local codes?
Reduced Pressure Princi�le Assemblv Pressure Vacuum Breaker
Double Check Valve Assembly
Relief Valve Air Inlet Check Valve
I st Check 2nd Check
1�'•' Held at�Opsid Held at ( .g psid Opcned at____ Opcnccl at Hcld at
Initial Test Closcd TighC✓ Cl�scd Tight ./ psid psid psicl
Leaked Leaked Did not open Did not open Leaked
Repai rs/
Materials �
Used
Hcld�t psid Hcld at psid
Test After � Opcncd at Opeued at Held at
Repair ClosedTight ! ClosedTight psid psid psid
Test gauge used: Make/Model_��p 40-200-tk5u SN: 04142867
Date Tested for Acct►racy: 5/4/2015
Remarks�
The above is certified to be true at the time of testing.
Finn Name Diamondbadc Fire Protection Finn Address PO Box 2507. Waxahachie,TX 75168
Cet-tified Tester(pr�rt)Joe Standrid�e CertiTied Tcster(signat�t��e
Firm Phone#_�214)444-3194 Cert.Tcstei-'�'o. BP0015823 __Date 10/23/2015
h TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
r��USE ONLY MANUFACTURER'S REPLACEMENT'PARTS
Whitc-City Copy Yello���-C'ustomer Copy Pink-Tester's Copy