2012_0213 (3)T H E � G 1 T Y � O F
COPPELL
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IRRIGATION DOMESTIC ..- � FIRELINE V
BACKFZOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS: Valley Ranch Baptist Church
PWS I.D. #
LOCATION OF SERVICE: 1501 E Belt Line Rd Connell Ts 75019
The backtlow• 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
o /Reduced Pressure Principle � Pressure Va�-en -*+n Breaker
p/ Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Watts Size g,.
Model Number 774X Located At NE Vault Fire Line
Serial Number 100142
The above is certified to be true.
Firm Name 1 -A Fire 8z Domestic Testing Certified Testa Brian L. Wagoner CELL # 817- 247 -4799
Firm Address P.O.Box 79548 Ft Worth Tx 767 79 CerL Tester No. BP0006563 Date Z � 3 Za/ Z
Gauge # 0073178 or 06070576
Date last accuracy tested Dec U 1 201 1
White - Customer's Copy � Yellow -City Copy Pirtle - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFAi.'"FR
Double Check Valve Assembly
1st Chec3:
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Closed Tight �
Opened at
Opened at
nsid
Ti�u
Leaked o
psid
nsid
��
RP- ( .,nsid
Leaked o
i . '�
Did not Oprn �
Leaked a
RcP�;r�
and
Materials
Used
Test Af%cr
DC- Closed
Closed Tight o
Opened at
Opened at
nsid
Repair
Tight a
nsid
nsid
RP sid
The above is certified to be true.
Firm Name 1 -A Fire 8z Domestic Testing Certified Testa Brian L. Wagoner CELL # 817- 247 -4799
Firm Address P.O.Box 79548 Ft Worth Tx 767 79 CerL Tester No. BP0006563 Date Z � 3 Za/ Z
Gauge # 0073178 or 06070576
Date last accuracy tested Dec U 1 201 1
White - Customer's Copy � Yellow -City Copy Pirtle - Tester's Copy