1530ESandyLake_75019_51569 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-22052
Test Date: 10/3/2018
Result: Passed
Reason for Test: Existing
Account Name : River Oaks Assisted Living
Address of Assembly : 1530 E Sandy Lake
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 :Double Check Valve Frequency :Annual What does this serve? FireLine
Manufacturer :Watts Model No :007M2QT Size :8 Serial No :MG0145
Location At:vault
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:10/3/2018
Time:9:20 AM
Held at 2.8 psid
Closed Tight
Leaked
Held at 2.8 psid
Closed Tight
Leaked
Opened at 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: Wilkins Model: TG-5 Serial No.: 04100962
Date Tested for Accuracy: 3/29/2018
Remarks :
Firm Name : Total Fire and Safety,Inc.Licensed Tester : Jesus Ancelmo
Firm Address : 7909 Carr St.BPAT License # : BP0016875
Firm Phone No : 214-381-6116 License Expiration Date : 10/14/2018
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.