2012_0213 (4)T N E � C 1 T Y - O F
COPPELL
��
CIIECK ONE. ��= �- .� /
IRRIGATION DOMESTIC n FIRELINE ✓
BACKFI.OW PREVENTION ASSEMBLY TEST AND MAIN'T'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
fl / Reduced Presstac Principle � Pressure Vacuimm Breaker
p/ Double Check Valve � Atmosphere Vacuum Breaker
Manufacaacr Watts Si=c 3/4"
Model Number 007M 1 Located At NE Vault Fire By -Pass
Serial Number 50628
The above is certified to be true.
Firm Name 1 -A Fire 8c Domestic Testing Certified Tester Brian L. WaQOner CE /LL # 817 - 247 -4799
Firm Addtrss P_O,Bo�: 79548 Ft worth Tr 761 79 Geri Testa No. BP0006562 Date ,� // �� /z0/ Z
Gauge # 007317R or 06070576
Date last accuracy tested Dec O 1 2011
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRFALCF'R
Double Cbecic Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Islet
Check Valve
Initial Test
DC- Closed
Tilt �
RP- � ,� nsid
Leaked �
Closed Tight �
Leaked �
�
Opened ai
nsid
Opened at
nsid
Did not Open o
nsid
Leaked o
�P airs
gad
Materials
Used
Tact ARer
DC- Closed
Closed Tight o
OP�� at
Opmod at
nsid
Repair
Tight n
nsid
nsid
RP sid
The above is certified to be true.
Firm Name 1 -A Fire 8c Domestic Testing Certified Tester Brian L. WaQOner CE /LL # 817 - 247 -4799
Firm Addtrss P_O,Bo�: 79548 Ft worth Tr 761 79 Geri Testa No. BP0006562 Date ,� // �� /z0/ Z
Gauge # 007317R or 06070576
Date last accuracy tested Dec O 1 2011
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy