2015_1023 IRRIGATION DOMESTIC FIREUNE X
The fo11o4ving form must be completed for each assemUlv tested. A signed and dated original
must be sub�niTted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION A�SEMBL4'TEST A1�1D:��IAi!RTTENA!i'CE REPORT
NAME OF PWS: CI1'Y OF COPPELL Pw�S I.D. #0570040
(Custon�er}
MAILING ADDRESS: 253 Club Circle Dr Co�pell TX 75019
CONTACT PERSON/PHONE: Denise 214930-0933
LOCATION OF SERVICE: '�
The backflow prevention assembl_y detailed belo�r ha een tested and maiutaii�ed as required by
commission reQulations and is certified to be operating��ithin�iccei�table paramcters.
TYPE OF�►SS�NI�LS'
Reduced Pressure Principle Reduced Pressure Principie-Detector
X Double Check Valve :Double C'l�eck-Detector �
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacturer__ +��g 1�Iodel Number�� Size L`�
Located At� n Seria] Numbet�_ /S�d�
Is the assembly i�lstalied in accordance witll mantifacturer recommendations and%or local codes'?
Reduced Pressure Princi�ie Assemblti� I'ressure��acuum B�•eaker
Double Check Valve Assembly
1 st Check � Relief Vahre Air Inlet Check Valve
nd Chcck
�� Held a1��psid Held c�t \.lo psid O��er�ed aC__� Opcncd at Held at
Initial Test Closcd Tight ✓ Closcd Tight � psid psid pti��j
Leaked L�akeci Did not open Did not open Leaked
Repairs/
Materials �
Used
Hcld at psici Hcl�l at psid
Test After Opcncd at " Opened at Held at
Repair GlosedTight : ClosedTight psid psid psid
Test gauge used: Make/Model Ilo 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Retnarks:
The above is certified to be true at the tin�e of testing.
Firn1 Name Diamondbaek Fire Protection Finn Address PO Box 2507. WaxaF�achie TX 75168
Certitied Tester(pris�t)Joe St ndridae Certitied Tcstei-(signatttr•
Firm Phone# (214) 444-3194 C�rt.Tester No. BP0015823 I)ate 10 23/2015
"TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�� USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-Gity Copy Yello«�-Customer Copy Pink-Tester's Copy