2014_0312 (4)ClIECK ONE:
IRRIGATION= DOMESTIC-0- FIRELIN
BACKYLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. 4
LOCATION OF SERVICE: 217 Wrangler Drive Coppell, Tx.
The backflow prevention assernbly 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 Pressure Vacuum Breaker
RIV Double Check Valve H A=osph= Vacuum Breaker
Manufacturer Hersey Size 811
Model Number DC 11 Located At SE corner of building
Serial Number 0005691
The I j
The above is certified to be true.
Firm Name Action Fire Pros Certified Tester Allen Stevens.,
PO Box 797 Waxahachie BP0009860 3-12-14
Firm Addrew Cep Tester No. Date
Gauge it 07090476
Date last accuracy tested 9-27-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY P
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
Ist Check t
tad Check R
Relief Valve A
Air Inlet C
Check Valve
Initial Test D
DC-Closed C
Closed Tight O
Opened at O
Opened at p
psid
,1�51V R
Tigh Ev L
Leaked E: -
------psid -
-------psid
Leaked
Repairs
and
Materials
Used
Test After D
DC-Closed C
Closed Tight C3 O
Opened at O
Opened at n
nsid
Repair T
Tight P
Paid -
------psid
RP===--
aid
The above is certified to be true.
Firm Name Action Fire Pros Certified Tester Allen Stevens.,
PO Box 797 Waxahachie BP0009860 3-12-14
Firm Addrew Cep Tester No. Date
Gauge it 07090476
Date last accuracy tested 9-27-13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy