2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assembly tested. A signed �lI1C{ dated oribinal
must be submitted to the�ublic watei-supplier for recordkeeping purposes:
BACKFLOW PREVEI�IT�ON.�SSEMBLY TEST A1�,`D iV�t�I?VT'ENANCE REPORT
NAME OF PWS: CITY OF COPPELL PWS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr CoRpell TX 75019
CONTACT PERSO�I/PHONE: Denise 214930-0933
LOCATION OF SERVICE:
The backflow prevention assembly detailed belo��=ha een tested and maintained as required by
commission re�ulations and is certitied ta be operating���ithin acceptable p��ran�eter�.
7'YPE OF'�SSElO�IBL'�
Reduced Pressure Principle Reduced Pressure Principle-Detector
X Double Cl�eck Valve Double Gheck-Detector
PressureVacuu�nBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufachu-er A�� Nlodel Number �tL�.1pp$ Size 1"
Located At Se►-ial Number IS(e$�`�
!s the assembly instalie in accordance with manufacturer recon�mendatiot�s and,�or local codes'?
Rcduced Pressurc Princi�le Assembl�� Pa-essure l'aeuum Breaker
Double Check Valve Assembly
Retief Vah-e Air Inlet Check Valve
I st Check 2nd Clieck
� Held at�,�psid Held at��psid Opened at. O��ened at Hcld at
Initial Test C'loscd Tight ✓ Closcd Tight ✓ psid psi�t ptii�
Leaked Leaked Did not open Di�l not apen Leaked
Repairsl
Materials ti
Used
Hcld at psid Hel�at psic!
Test After Opcncd at Opened at Held at
Repair C]osedTight ; ClosedTight - psid psid ps+d
Test gauge used: Make/Model��oll0 40-200-tk5u SN: 04142867
Date Tested for Accuracy: 5/4/2015
Remarks:
The above is certified to be n•ue at the tiine of testing.
Firm Namc Diamondbadc Fire Protection Finn Address PO Box 2507,Waxahachie.TX 75168
Certitled Tester(}��-;r.t�oe Standridge Certified Tcster(signatrn��;j_
Finn Phone# (214) 444-3194 Cert.Tester�o. BP0015823 Date 10/23/2015
�`TEST I�ECORDS MUST BE KEPT FOR AT LEAST THREE YE.ARS
'�*USE ONLY MANUF.ACTURER'S REPLACEMENT PARTS
White-City Copy Yellow-Customer Copy Pink-Tester's Copy