920S_BeltlineRd_Ste250_75019_80799 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-22419
Test Date: 10/23/2019
Result: Passed
Reason for Test: Existing
Account Name : Integrity Wellness Center
Address of Assembly : 920 S.Beltline Rd.Ste 250 : 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 :LF009M2QT ByPass : Size :1 1/4 ByPass : Serial No :04418 ByPass :
Location At:Utility Room
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:10/23/2019
Time:3:00 PM
Held at 8.4 psid
Closed Tight
Leaked
Held at 8.2 psid
Closed Tight
Leaked
Opened at 2.4
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: Potable Make: Wilkins Model: TG-5 Serial No.: 12142147
Date Tested for Accuracy: 2/8/2019
Remarks :
Firm Name : Approved Backflow Testing Licensed Tester : Douglas Rose
Firm Address : 1303 W Main St BPAT License # : BP0011099
Firm Phone No : 214-477-7002 License Expiration Date : 02/04/2020
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.