2014_0312 (7)CHECK ONE:
IRRIGATION_,D_ DOMESTIC___Z_ FIRELINE��`
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS;
PWS I.D. #
LOCATION OF SERVICE: 217 Wrangler Drive Coppell, Tx.
The backilow prevention assembly detailed below has been tested and maintained as required by TCEQ
regulations and is certified to be operating within acceptable parameters.
Serial Number 162722
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
sin
2"
Located At S. Wall - Chiller room
Reduced Pressure Principle
PRESSURE VACUUM BREAKER
Double Check Valve
Manufacturer
Watts
Model Number
009M2
1st Check
Serial Number 162722
TYPE OF ASSEMBLY
Pressure Vacuum Breaker
Atmosphere Vacuum Breaker
sin
2"
Located At S. Wall - Chiller room
The above is certified to be true.
Firm Name Action Fire Pros Certified Testm Allen Stevens
Firm Address PO Box 797 Waxahachie Cert. Tester No BP0009860 Date 3 -12 -14
Gauge # 07090476
Date last accuracy tested 9 -27 -13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check valve Assembly
1st Check
tad Check
Relief Valve
Air inlet
Check Valve
Initial Test
g
DC- Closed
Tight
RP -�si
Leaked
Closed Tight
Leaked
g +
Opened at
i 1 psid
Opined at
asid
Did not Opcn o
_ --asid
larked O
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight a
RP sid
Closed Tight o
Opened at
asid
Opened at
insid
Psid
The above is certified to be true.
Firm Name Action Fire Pros Certified Testm Allen Stevens
Firm Address PO Box 797 Waxahachie Cert. Tester No BP0009860 Date 3 -12 -14
Gauge # 07090476
Date last accuracy tested 9 -27 -13
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy