731PlazaBlvd_75019_128556 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-28262
Test Date: 11/30/2020
Result: Passed
Reason for Test: Existing
Account Name : COPPELL SURGERY CENTER
Address of Assembly : 731 Plaza Blvd : 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? Domestic
Manufacturer :Watts ByPass : Model No :007 ByPass : Size :1/2 ByPass : Serial No :29842 ByPass :
Location At:room 108
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:11/30/2020
Time:11:00 AM
Held at 8.8 psid
Closed Tight
Leaked
Held at 9.1
psid
Closed Tight
Leaked
Opened at
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: Apollo Model: 40-200-TK5U Serial No.: 09142374
Date Tested for Accuracy: 10/29/2020
Remarks :PASS
Firm Name : Cintas Fire Protection Licensed Tester : James Steven Mitchell
Firm Address : 751 109th St.BPAT License # : BP0010924
Firm Phone No : 817-640-2223 License Expiration Date : 11/12/2022
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.