2015_1023 IRRIGATION DOMESTIC FIRELlNE X
The following fonn must be completed for each assemblv testcd. A signcd and dated original
must be submitted to the public��vater supplier for recordkeeping puiposes:
SACKFLOW PRE'b'ENTIOIY A�SEMBL�'TE�T Al�'D�7A�c�'TE�dANCE REPORT
NAME OF PWS: CITY OF COPPELL PW'S I.D. #0570040
(Customer)
MAILING ADDRESS: 253 Cluh Circle Dr Cot�ell TX 75019
CONTACT PERSO�I/PHONE: Denise 214930-0933
LOCATION OF SERVICE: �
The backflow prevention assembly detailed be �as been tested and maiiitained as required by
commission regulations and is certificd to be operating�vitllin accei�table����rameters.
T'�'PE OF ASS��IBLY
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Clleck Valve Double Check-Detector
Pressure Vacuum Breaker Spi1l=Resistant Pressure Vacuum Breaker
Manufactui•er f�y�y�,eg tYlodel Nilmber �� Size /'�
Located At_�� Serial Number �SlSO
Is the assembly installe�in accordance witll manufacturer recomme�ldations and%or local codes'?��S
Reduced Pressurc Princi�le Assembl�� Pressure��acuum Breaker
Double Check Valve Assembly
Retief Vah�e Air Inlet Check Valve
I st Check 2nd Check
Tu� Held at�.�psici Held at Z.•� }�sid O��cned at__� npriied�it Held at
Initial Test Closcd Tight ✓ Closcd Tight ✓ psicf psid ps��(
Leaked Le�ked Did not open Did i�ot apen Leaked
Repairs/
Materials i
Used �
Held at psid Hcic!at psid
Test After Opcned at Opened at Held at
Repair Clased Tight i Closed Tight psid p�id psid
Test gauge used: Make/Model�I�p 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Reinarks:
The above is certified to be true at the time of testin�.
Finn Name Diamondbadc Fire Protection Firnl Addi•ess PO Box 2507. Waxahachie TX 75168
Certitied Testcr(prirt)Joe Standridqe _Certitied Tcstcr(si��natt�re
Firm Phone# (214}444-3194 Cc►-t.Testei-�o. BP0015823 Date 10/23 015
"TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�� USE ONLY MANUFACTURER'S REPLACEMENT PART'S
White-City Copy Yello���-Customer Copy Pink-Tester's Copy