2015_1023 IRRIGATION DOMESTIC FIRELlNE X
The follo�ving fonn must be completed for each asseinbl_y tested. A signed a�ld dated original
must be submitted to the public water supplier for recordkeeping p�n-�oses:
Bf1CKFLOW PRE�'ENTpON.�SSEMBLY TES'C�1�I�iVe�[i�'T�'VA��E REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #U�700�0
(Customer)
iV1AILING ADDRESS: 253 Club Circle Dr Coppell TX 75019
CONTACT PERSON/PHONE: Denise 214930-0933
LOCATION OF SERVICE:
The backflow prevention assembly detailed belo�� as been tested and mailitained as required by
commission regulations and is certificd to be operating���itllin acceptable��trameters.
TYPE OF�SS��I�L�'
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Check Valve :Double Check-Detector
PressureVacuuinBreal�er Spi1l=Resistant Presstue Vacuum Breaker
Manufacturer I�,�4 Model Number �DOp,� Size �"
Located At c Sei-ial Numher�u��n� reas-� �k
Is the assembly installe in accordance with manufacturer recomme�ldations and/or local codes'?
Reduced Pressum Princi�le Assembl�� Pressure�'acuum Breaker
Double Check Valve AssemUly
Relief Valve Air Inlet Check Valve
1 st Check 2nd Check
� Held at ��� psid Held aT �.(o psid Opcned at___ Open�d at �He(d at
Initial Test Closcd Tight ✓ Closcd Tight ✓ psid }�sid psid
Leaked L�aked Did not open Did not open Leaked
Repairs/
Materials
Used
Hcid at psid Hcicf at psid
Test After Opet�cd at Opened at Held at
Repair Closed Tight ` Closed Tight psid psid psid
Test�auge usee�_ Make/Model�q�ollo 40-200-tk5u SN: 04142867
Date Tested foe Accuracy: 5/4/2015
Remarks:
The above is certified to be true at the time of testin,.
Finn Name Diamondbadc Fire Proteetion Finn Add�-ess_PO Box 2507. Waxahachie.TX 75168
Certified Testcr(pr;�•�t)�oe$tandridae Certiticd Tcster(signa[ure `
Firm Phrnle# (214)4443194 Ccrt.Tcster 1i�. BP0015823 Uate 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
*'^USE ONLY MANUt=ACTURER'S REPLACEMENT PARTS
White-City Copy Yello�i�-Customer Copy Pink-Tester's Copy