2012_0213 (5)T M E - C 1 T Y � O F
COPPELL_
CIIECK ONE: W- �' �- _
/ _ ri
IRRIGATION ✓ DOMESTIC V FIRELINE
BACICIN3.OW 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 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
O Reduced Pressut-c Principle o Pressure Va�-+n�*++ Breaker
Double Check Valve o Atmosphere Vacuum Breaker
Manufacturer Watts Size 2'>
Model N>mmber 007M 1 Located At North side of oroner[v Irrigation
Serial Number
The above is certified to be true_
Firm Name 1 -A Fire 8c Domestic Testing Catified Tester Brian L. Wagoner CELL # 817 - 247 -4799
Firm Address P_O -Bow 79548 Ft worth Tx 761 79 Cent Testa No. BP0006562 Dam Z / 3 ZO/ Z
Gauge # 0073 ] 78 or 06070576
Date last accuracy tested Deo O1 201 1
White - Customer's Copy Yellow -City Copy Pink - Testers Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BRE_A�R
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
Closed Tight L1
Opened at
Opened at
osid
Ti�htt
RP- i � ` sin �-
Lcal:ed O
Leaked � o
_
+ � �
osid
osid
Did not OpeII o
Leaked o
Repairs
and
Mata-ials
Used
Test AR,er
DC- Closed
Closed Tight o
OPmed at
Opined at
osid
Repair
Tight Q
osid
osid
RP sid
The above is certified to be true_
Firm Name 1 -A Fire 8c Domestic Testing Catified Tester Brian L. Wagoner CELL # 817 - 247 -4799
Firm Address P_O -Bow 79548 Ft worth Tx 761 79 Cent Testa No. BP0006562 Dam Z / 3 ZO/ Z
Gauge # 0073 ] 78 or 06070576
Date last accuracy tested Deo O1 201 1
White - Customer's Copy Yellow -City Copy Pink - Testers Copy