2012_0213T H E � C I T Y � O F
COPPELL
CIIECK ONE= V ,:_
IRRIGATION DOMESTIC FIRELINE
BACKFT.OW PREVENTION ASSEMBLY TEST AND MAII�TI'ENANCE REPORT
NAME OF PWS: Valley Ranch Baptist Church
PWS I_D_ #
LOCATION OF SERVICE: 1501 E Belt Line Rd Connell Tx 75019
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ / Reduced Pressure Principle o Pressure Va�-+n**•+ Breaker
�/ Double Check V "aloe ❑ Atmosphere Vacutmm Breaker
Manufacturer Hersey Size 6"
Model Number DDCII Located Ai NW Vault Fire Line
Serial Nvmber 9403341
The above is certified to be true.
Firm Name 1 -A Fire Bz Domestic Testing Certified Testa Brian L. Wagoner CELL # 817- 247 -4799
Firm Addres.4 P O.Bo� 79548 Ft worth T�: 76179 Cat Testa No. BP0006562 Date Z / ? v/ Z
Gauge � 0073178 or 0607(1576
Date last accuracy tested Dec O1 2011
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Checl:
2nd Chekl:
Relief Vaive
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Tilt
l -nsid
Leaked ❑
psid
nsid
RP-
j � Lp
Leaked o
Did not Oprn o
Leaked ❑
�Pa;�
and
Materials
Used
Test Af%er
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tigitt a
nsid
nsid
RP sid
The above is certified to be true.
Firm Name 1 -A Fire Bz Domestic Testing Certified Testa Brian L. Wagoner CELL # 817- 247 -4799
Firm Addres.4 P O.Bo� 79548 Ft worth T�: 76179 Cat Testa No. BP0006562 Date Z / ? v/ Z
Gauge � 0073178 or 0607(1576
Date last accuracy tested Dec O1 2011
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy