503Evergreen_75019_110522 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-22322
Test Date: 7/22/2020
Result: Passed
Reason for Test: Existing
Account Name : Current Water Customer
Address of Assembly : 503 Evergreen : Address Type : Residential
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 :Wilkins ByPass : Model No :375XL ByPass : Size :1 ByPass : Serial No :B128751 ByPass :
Location At:Health Containment
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:7/22/2020
Time:8:20 AM
Held at 9.2 psid
Closed Tight
Leaked
Held at 8.8 psid
Closed Tight
Leaked
Opened at 2.2
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 and
Materials Used **
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/ZURN Model: TG5 Serial No.: 03181401
Date Tested for Accuracy: 3/25/2020
Remarks :
Firm Name : RD MOORMAN,INC Licensed Tester : MOSES KEMP
Firm Address : 417 WYNDEMERE BLVD BPAT License # : BP0014971
Firm Phone No : 972-722-2408 License Expiration Date : 11/30/2021
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.