NEW_137TX-121Ste_110_75019_82926 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-69196
Test Date: 11/25/2019
Result: Passed
Reason for Test: New
Account Name : Coppell Pediatric Dentistry
Address of Assembly : 137 TX-121 Ste.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 ByPass : Model No :LF009M2 ByPass : Size :1"ByPass : Serial No :179476 ByPass :
Location At:In utility closet
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)?Yes
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:11/25/2019
Time:8:00 AM
Held at 8.6 psid
Closed Tight
Leaked
Held at 8.6 psid
Closed Tight
Leaked
Opened at 3
psid
Did not open
Held at psid
Closed Tight
Leaked
Opened at psid
Did not open
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: Non-Potable Make: Midwest Model: 845-5 Serial No.: 11130531
Date Tested for Accuracy: 3/11/2019
Remarks :
Firm Name : .01 Accuracy Backflow Licensed Tester : Brian Cox
Firm Address : P.O.Box 6832 BPAT License # : BP0017066
Firm Phone No : 972.699.7156 License Expiration Date : 02/23/2022
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.