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IRRIGATION-0— DOMESTIC-0— FIRELIKE W1
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OFPWS: 1('C,,21,2rzz
PWS I.D.
LOCATION OF SERVICE: 217 Wrangler Drive Coppell, Tx.
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 7LY
Reduced Pressure Principle Pressure Vacuum Breaker
HV/ Double Check Valve Atmosphere Vacuum Breaker
Mauufa=er Hersey size 811
Model Number DC 11 Located At SW corner of building
Serial Number 0005690
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Initial Test
DC-Closod
Closed tight
Opened at
opened at
sid
Tight
R 3,49 R
Leaked
_psid
osid
10- / - -, � sif
Did Open 0
Leaked fl
Leaked
not
Repairs
and
Materials
Used
Test After
DC-Closed
Closed Tight a
Opened at
Opened at
---- psid
Repair
Tight a
psid
-_-_--.psid
R....2sid
The above is certified to be true.
Action Fire Pros Certified Testa Allen Stevens
Firm Name
Firm Address PO Box 797 Waxahachie cdt Testa No. BP0009860 Due 3-12-14
Gauge # 07090476
Date last accuracy tested 9-27-13
White - Customer's Copy Yellow - City Copy Pink - Tester-s Copy