2015_1023 IRRIGATION DOMESTIC FIRELINE X
The following form must be completed for each assemhl_y testeci. A si�ned and ciated oribinal
must be subinitted to the public water supplier for recordkeeping purposes:
BACKFLOW PREVENTION.�SSEMBL�'TEST Ah'D � .4I��TL�N.��e'CE REPORT
NAME OF PWS: CITY OF COPPELL PVvS I.D. #0�70040
(Customer)
MAILING ADDRESS: 253 Club Circle Dr Co�ell TX 75019
CONTACT PERSON,�PH4NE: Denise 214930-0933
LOCATION OF SERVICE: 2�J„�J,�_��
The backflow pre��ention assembly detailed belo� ]�as been tested and maintained as required by
commission regulations and is certified to be operatiiig�vithin accep�able naramete�s.
'�'YPE O�ASS�1l��BL.Y
Reduced Pressure Principle Reduced Pressiire Principle-Detector
XDoubleCl�eckVah�e Double Check-Detector
PressureVacuumBreaker Spi1l=Resistant Pressure Vacuum Breaker
Manufacriirer_��g YiodelI�lumber ,��$ Size l�
Located At� Serial Number �31'}�
Is the assembly installe n accordance with rr►ai�ufacturer recominendations and/or local codes?
Reduced Pressurc Princi�le Assembi� Pressurc Vacuum Breaker
Double Check Valve Assembly
Relief Vah,e Air Inlet Check Val��e
1 st Check 2nd Check
�� Held at �psid Held at_ psid Opened�it_ Opened at Held at
Initial Test Closed Tight Closed Tight psid psici p5i�
Leaked � Leaked Did not open Did not open Leak�d
Repairs/
Materials
Used
Hcld�t psid Held at psic!
Test After Opcncd at Upcnecl at Held at
Repair ClosedTight : ClosedTight ps�� ps�d ps��
Test gauge used: Make/Model Aool�o 40-200-tk5u SN: 04142867
Date Tested for Acc�u•acy: 5/4/2015
Remarks_
The above is certified to be true at the ti�ne of testin�.
Finn Name Diamondbadc Fire Protection Finn Address PO Box 2507. Waxahaehie TX 75168
Certitled Tester(�r:�-t�oe Standrida�__ Certitiect Testcr(signattn-
E inn Phone# (214) 44�4-3194 Cert.Testcr�o. BP0015823 I�ate 10/23 015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
'*USE ONLY MANUFACTURFR'S REPLACEMENT PARTS
White-City Copy Yello�v-Customer Copy Pink-Tester's Copy