2015_1023 1RRIGATION DOMESTIC FlRELINE X
� The following form must be completed for each asser��bly tested. A signed and dated oribinal
must be submitted to the�ublic watcr supplier for recordkeeping purposes:
BACKFLOW PREVENTION,ASSEMBLY'FEST�h�D MP,I:�'TENANCE REPORT
NAME OF PWS: CITY OF C'OPPELL PVvS I.D. #Q�70�40
(Customer)
MAILING ADDRESS: 253 Club Circle Dr CoRpell TX 75019
CONTACT PERSON/PHONE: Denise 214930-0933
LOCATION OF SERVICE:��� L;�I�P��-„
The backflow prevention assembly detailed belo«-has been tested and maintained as required b_y
comnlission regulations and is certifiecl to be operating���ithin acceptable Iiaran�cters.
7'YPE O�r�SSEN��L�
Reduced Pressure Principle Redt�ced Presstne Principle-Detector
XDoubleCheckVah�e Double Check-Detector
PressureVacuuinBreaker Spi1l=Rzsistant Pressure Vactium Breaker
Manufacturer �y,.�,�� Ni�del Nuitiber_�DOC�8 Size___(�__
Located At l�o..�ro.oe Seiial Num�es- Abl �9 l
Is the assembly installed in accordance��ith manufacturer recommendations and%or local codes'' Ve5
Reduced Pressurc Princi�le Assembhr Pressure�'acuum Breaker
Double Check Vaive Assembly
1 st Check � Relief Valve Air Inlet Check Valve
nd Check
� Held at�O psid Heid at��sid Open�d at_ Opened at Hcld at
lniti�l Test Closed Tight✓ Closed Ti�ht ✓ psid psid psi�{
Leaked Leaked Did not open Did not open Leaked
Repairs/
Materials �
Used
Hcid at psid Hcid ai psid
Test After Opuncd at Openc;d at Held at
Repair ClosedTight ; ClosedTight ps�� E„�d psid
Test gauge used: Make/Model_p�ollo 40-200-tk5u SN: 04142867
Date Tested for Acctn•acy: 5/4/2015
Remarks:
The above is certified to be true at tile ti�ne of testin�.
Fii�n Name Diamondback Fire Protection Finr► Address PO Box 2507.Waxahachie TX 75168
Certified Tester(�r:�-t)Joe Standrid�c�_ Certitied Tester(si;�natur
�=inn Phone# (214) 444-3194 Cert_Tester:�o. BP0015823 Date 10/23/2015
�TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
�*USE ONLY MANUFACTURFR'S REPLACEMENT FARTS
White-City Copy Yello���-Customer Copy Pink-Tester's Copy