1233LakeShoreDr_75019_76595 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-47870
Test Date: 8/30/2019
Result: Passed
Reason for Test: Existing
Account Name : Current Water Customer
Address of Assembly : 1233 Lake Shore Dr
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 :Ames ByPass : Model No :Colt 300 ByPass : Size :6 ByPass : Serial No :TG1833 ByPass :
Location At:East side entrance in 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 Type II
Assembly
Pressure Vacuum Breaker
Spilled-Resistant Vacuum BreakerDoubleCheckValveAssembly
1st check 2nd check Relief Valve Bypass Check Air Inlet Check Valve
Initial Test
Date:8/30/2019
Time:8:00 AM
Held at 2 psid
Closed Tight
Leaked
Held at 2.8 psid
Closed Tight
Leaked
Opened at psid
Did not open
Held at psid
Closed Tight
Leaked
Opened at psid
Did it fully open
Yes No
Held at psid
Leaked
Repairs andMaterialsUsed **
Test After Repair
Date:
Time:
Held at psid
Closed Tight
Leaked
Held at psid
Closed Tight
Leaked
Opened at psid Held at psid
Closed Tight
Leaked
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.: 07172120
Date Tested for Accuracy: 2/12/2019
Remarks :
Firm Name : Northstar Fire Protection Licensed Tester : Henry Pios
Firm Address : 510 E Corporate Drive Suite 700 BPAT License # : BP0013269
Firm Phone No : 469-293-1489 License Expiration Date : 08/18/2022
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.