477W_BethelRoad_75019_35961 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
City:Coppell
PWS I.D.:0570040
Address:816 S.Coppell Road
Coppell,Texas 75019
Phone:972-462-5150
Contact Person:Jerry Davis
Catalog No: TXTCOP-21315
Result: Passed
Account Name : Local Diner (Coppell)
Address of Assembly : 477 W.Bethel Road
Address Type : Commercial
Inspection
The backflow prevention assembly detailed below has been tested as required by TCEQ regulations and is certified to be
operating within acceptable parameters.
Type of Assembly :Reduced Pressure Principle Frequency :Annual
Manufacturer :Watts Model No :SS009M3QT Size :1/2 Serial No :15223
Location At:Kitchen at carbonator
What does this serve? Domestic
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?Yes
Reduced Pressure Principle Assembly Pressure Vacuum Breaker
Double Check Valve Assembly
1st check 2nd check Relief Valve Air Inlet Check Valve
Held at 8.2 psid
Closed Tight
Leaked
Held at 8.2 psid
Closed Tight
Leaked
Opened at 2.2 psid
Did not open
Opened at psid
Did not open
Held at psid
Leaked
Repairs and Materials Used
Test Results after Repair
1st check 2nd check Relief Valve Air Inlet Check Valve
Held at psid
Closed Tight
Leaked
Held at psid
Closed Tight
Leaked
Opened at psid Opened at psid Held at psid
Remarks :
Test gauge used : Potable
Make : Longhorn Model : 845-5 Serial No. : 08040583 Date Tested for Accuracy : 10/9/2017
The above is certified to be true at the time of testing.
Firm name : A &A Active Backflow Certified Tester : Christopher Gafford
Firm Address : 1611 N IH 35E Ste 410 Certified Tester No. : BP0013306 Exp.Date : 09/13/2019
Firm Phone No : 972-242-2229 Test Date : 11/8/2017
*Test Records must be kept for at least three years.
**Use only manufacturer's replacement parts.
The following form must be completed for each assembly tested.