2012_0213 (2)T M E � 1 T Y - O f
COPPELL
CHECK ONE. � � - __ -
IRRIGATION DOMESTIC FIRELIN E
BACKFT.OW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: Valley Ranch Baptist Chr�ueh
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 ccrtilied to be operating within acceptable parameters.
TYPE OF ASSEMBLY
o / Reduced Pressure Principle n Pressure Vacu�an Breaker
r.�/ Double Check Vaivc � Atmosphere Vacuum Breaker
Manufacturer Hersey Siu 3/4"
Model Number FDC Located At NW Vault Fire Luie L3 v •Pis ,
Serial Number 166339 F °' l �`!�/ L° s r � �'s� [ait� T��- !.•..,e �,c� i ar�� w
C�oyy�.
The above is certified to be true.
Firm Name 1 -A Fire Sc Domestic Testing Certified Tester Brian L. Wagoner CELL # 817- 247 -4799
Firm Address P O.Box 7954R Ft worth Tx 761 79 Cent. Tester No. BP0006562 Date - ='_�/ 3fZG/ Z
Gauge � 007317R or 06070576
Date last accuracy tested Dec U 1 201 1
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM $RFaKF'R
Double Check Valve Assembly
1st Cbeck
2nd Checl:
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight Q
Opened at
Oprned at
osid
�,�� �
Ti�tL t7
RP- osid
Leaked �
psid
osid
Leaked o
Did not Opea o
Leaked a
�P�
and
Materials
��
�- ��--'�
SS
Used
Test ARer
DC- Closed
Closed Tight o
Opened at
Opined at
osid
Repair
Tight �
nsid
osid
RP sid
The above is certified to be true.
Firm Name 1 -A Fire Sc Domestic Testing Certified Tester Brian L. Wagoner CELL # 817- 247 -4799
Firm Address P O.Box 7954R Ft worth Tx 761 79 Cent. Tester No. BP0006562 Date - ='_�/ 3fZG/ Z
Gauge � 007317R or 06070576
Date last accuracy tested Dec U 1 201 1
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy