2015_1023 IRRIGATION DOMESTIC FlRELlNE X
The folio�ving fonn must be completed far each assemblv tested. A signed and ciated origival
must be submitted to the public water supplier for recordkeeping p�n-poses:
BACKFLOW PRE�'ENTION A�SEMBLY TEST�l1�'�z'VI�Ii�TTENAtiCE REPORT
NAME OF PWS: CITY 4F COPPELL P�%S I.D. #0�70040
(Customer) �
MAILING ADDRESS: ��,3 Club Circle Dr Co�Aell TX 75019
CONTACT PERSON/PHONE: Denise 214-930-0933
LOCATION OF SERVICE:
The backflow preve�ition assembly detailed belo�� been tested and mai�itainect as required by
con�mission re�ulations and is certitied to be operating��=ithin acceptahle�arametc�s. �
TYPE O�AS�E�I�I,Y
Reduced Pressure Principle Reduced Pi�essure Principle-Detector
XDoubleCheck Valve Double Checl:-17etector
PressureVacuumBreaker Spill=Resistant Pressure Vacuum Breaker
Manufac;turer ��.y�Q,.g Model Number �� Size_�___[��_
Located �t Serial Nuinber_p�q2q
Is the assembly installed i accordance with mantifact�u-er recommeiidations and%or local codes'? 5
Reduced Pressure Princi�le Assemblti Pressure��acuum Breaker
Double Check Valve Assembly
Relief Vahre Air Inlet Check Vaive
l st Check 2nd Check
�l�v�" Held at�.',Z psici Held at 2-�psid Opened at____ Openecl at Hcld at
Initial Test Ctoscd Tight✓ Closcd Tight ✓ psid psi�l ��y��j
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials
usza i
I
Hcid at psid Hel�l at psid
Test After Opcned at Openccl at Held at
Repair ClosedTight ; ClosedTi�ht ps�� psid psid
Test gau�e used: Make/Modei o110 40-200-tk5u SN: 04.142gg7
Date Tested for Acciiracy: 5/4/2015
Remarks:
The above is certified to be n�ue at the time of testing.
Firin Name Diamondback Fire Proteetion Finn Address PO Box 2507. Waxahachie TX ?5168
Certitied Tester(�,i-:s:t)�oe Standridae Certitied Tester(si�,natur�,
Firm Phane# (214)4�4�4-3194 Ca-t.Tester\o. BP0015823 _Date 10/23 015
�TEST RECORDS ivIUST BE KEPT FOR AT LEAST THREE YEARS
�`� USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yelloi��-Customer Copy Pink-Tester's Copy