750CanyonDrive#110_75019_39924 BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Name of PWS:Coppell
PWS I.D.:0570040
Address:816 S.Coppell Road
Coppell,Texas 75019
Phone:972-462-5150
Contact Person:Jerry Davis
Catalog No: TXTCOP-22493
Test Date: 2/23/2018
Result: Passed
Reason for Test: Existing
Account Name : GH 750 Canyon,Inc
Address of Assembly : 750 Canyon Drive #110
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 What does this serve? Domestic
Manufacturer :Watts Model No :009QT Size :1/2 Serial No :400048
Location At:VMC Ste.#230 2nd floor coffee machine
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?Yes
Is the assembly installed on a non-potable water supply (auxiliary)?No
Reduced Pressure Principle Assembly Pressure Vacuum Breaker
Spilled-Resistant Vacuum BreakerDoubleCheckValveAssembly
1st check 2nd check Relief Valve Air Inlet Check Valve
Initial Test
Date:2/23/2018
Time:8:15 AM
Held at 8 psid
Closed Tight
Leaked
Held at 8 psid
Closed Tight
Leaked
Opened at 2.9 psid
Did not open
Opened at psid
Did it fully open
Yes No
Held at psid
Leaked
Repairs and Materials
Used **
Test After Repair
Date:
Time:
Held at psid
Closed Tight
Leaked
Held at psid
Closed Tight
Leaked
Opened at psid Opened at psid Held at psid
***2nd check:numeric reading required for DCVA only
Test gauge used: Potable Make: MID-WEST Model: 845-5 Serial No.: 12171801
Date Tested for Accuracy: 1/30/2018
Remarks :
Firm Name : Polk Mechanical Licensed Tester : Ryan Calhoun
Firm Address : 2425 Dillard St BPAT License # : BP0018224
Firm Phone No : (817)692-8639 License Expiration Date : 01/18/2021
The above is certified to be true at the time of testing.
* Test Records must be kept for at least three years.[30 TAC §290.46(B)]
** Use only manufacturer's replacement parts.