2015_1023 IRRIGATION DOMESTIC FlRELINE X
The follo�ving for�n must be completed for each assemblv testeci. A signcd and dated oribinal
must be submitted to the public water supplier for recordkeeping pin-poses:
BACKFLOW PRE1'ENTION A�SEMBLY TE�T Al�'Q M�Ii�'�'E'VA�CE REPORT
NAME OF PWS: C1TY OF COPPELL PVuS I.D. #0�70041�
(Gustomer) � � �
MAILING ADDRESS: 253 Club Circle Dr Copoell TX 75019
CONTACT PERSON/PHONE: penise 214-930-0933
LOCATION OF SERVICE: (Q
The backflow pre��ention assembly detailed belo� has een tested and maiiitained as required by
commission reaulations and is certified to be operating within acce�talile paran�eters.
TYPE O�ASSE?�I�LY
Reduced Pressure Principle Reduced Pressure Piinciple-Detector
X Double Check Valve Double Clieck-Detect�r
PressureVacuumBreaker 5pi11=Resistant Pressure Vacuum Breaker
Manufactui•er__ �-1yr..t5 viodel Number ��� Size (`'
Located At Cae,� Serial Numi�er ('i9Q'j
[s the assembly installe n accordance witl�mauufacturer recommendations and/or local codes? �
Reduced Presstirc Pi•inci�le Assembl} Pressure�lacuum Breaker
Double Cl�eck Valve AssemUly
Relief Vahje Air Inlet Check Valve
1 st Check 2nd Chcck
1'�� Held at�,Q psid Held at \•�6 psid C)��cned at____ Opcned at He(d at
Initial Test Closccl Tight ✓ Cluscd Tight ✓ psid psicl psid
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials I
Used
Hcld at psid Hcld at psid
Test After Opc��cd at Opened at Held at
Repair Closed Tight ` Closed Tight ., ps�d psid psid
Test gattge used: Make/Model�llo 40-200-tk5u SN:_ 04142867
Date Tested for Accuracy: 5/4/2015
Reinarks:
The above is certified to be t�•ue at the time of testing.
Fir�n Name Diamondback Fire Protection Firnl Address PO Box 2507. Waxahachie.TX 75168
CerCitied Tester(pr:r:t)Joe StanrJridae Ceirtified Tester(si�,natit�•e)
Firm Phone# (214)444-3194 Cert.Testei�;�c�. BP0015823 Uate 10/23 015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
��USE ONLY"MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello���-Customer Copy Pink-Tester's Copy