700RiverchaseDrive_75019_59586 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-22141
Test Date: 11/27/2018
Result: Passed
Reason for Test: Existing
Account Name : Riverchase Golf Club
Address of Assembly : 700 Riverchase Drive
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 :373043
Location At:Kitchen Dishwasher
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:11/27/2018
Time:10:00 AM
Held at 8.5 psid
Closed Tight
Leaked
Held at 9.8 psid
Closed Tight
Leaked
Opened at 3 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: Apollo Model: 40-200-TK5U Serial No.: 11100421
Date Tested for Accuracy: 12/18/2017
Remarks :
Firm Name : Backflow Services Licensed Tester : Sherman Dobbs
Firm Address : 16308 Dry Creek Blvd.BPAT License # : BP0013767
Firm Phone No : 469-500-5506 License Expiration Date : 08/11/2021
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.