2015_1023 IRRIGATION DOMESTIC FIRELINE X
The follo�ving form must be completed foi- each assembly teste�i. � signed Alld dated oi•iainal
must be subinitted to the public water supplier for recordkeeping ptn-poses:
BACKFLOW PRE�'ENTION�►�SEMBL4'�'EST ANI�"VIAI\'TENANCE REPORT
NAME OF PWS: CITY OF COPPELL PW`S I.D. #0�70040
(Gustomer)
MAILING ADDRESS: 253 Club Circle Dr Copc�eli TX 75019
CONTACT PERSO�'/PHONE: Denise 214930-0933
LOCATION OF SERVICE: ' �
The backflow prevention assembly detailed belo« s been tested and maint�ined as required by
commission regulations and is certified to be operacin��i�id�in accep�ahle paramLters.
TYPE OF�.SS�1l�IBI�Y
Reduced Pressure Principle Reduceci Pressure Principle-Detector
X Double Check Valve Do«ble Check-Detecror
PressureVacutunBreaker Spi]l=Resistant Pressure Vacuum Breaker
Manufacturer '�_
�vnsz' Ylodel Number �pQ(yg Size
Located At Vto�.eo.e�.P Serial Numbe�• 13'.��
Is the assembly installed in accordance with manufacturer recon�mei�dations and/or local codes"?V�S
Reduced Pressure Princi�le Assembl�� Pressure�'acuum Breaker
Double Check Valve Assembly
l st Check � Relief Vahre Air Inlet Check Valvc
nd Check
� Held at l�`6 psid Held at 2,y psi Opc»ed at__� Opened at He(d at
Initial Test Closcd Tight ✓ Clusccl Tight psid psi�1 ��Sid
Leaked Leaked Did not open Did not apen Leaked
Repairs/
Materials �
Used
Hcld at psid H�lci at psid
Test After Opcncd at ' Opencd at Held at
Repair Closed Tight : Closed Tight psid p�id psid
Test gau�e used: Make/Modet�p 40-200-tk5u SN:_ 04142867
Date 'Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be ti•ue at the time of testiva.
Firn�Name Diamondbaek Fire Protection Finn Address PO Box 2507. Waxahachie TX 75168
�
Certified Tester(pr:+=t�oe Standridae Certitied Tcster(si�,nature)
Firm Phone#_(214)444-3194 _ Cert.Testei-io:��. BP0015823 Date 10/23/2015
"TEST RECORDS iv1UST BE KEPT FOR AT LEAST THREE YEARS
��USE ONLY MANUFACTURER'S REPLACEMENT PARTS
White-City Copy Yello���-Customer Copy Pink-Tester's Copy