2013_0910City of Coppell
The following form must be completed for each assembly tested. A signed and dated original must be
submitted to the public water supplier for record keeping purposes:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Name of PWS: PWS I.D. #:
500 Southwestern * P. O. Box 94786 * Coppell, Texas 75019
972 - 304 -3509 * Recorder: 972 - 304 -3518 * Fax: 972 - 304 -3514
Name of Business GHET Medical ❑ Residential D Commercial
Address of Assembly: 720 N. Denton T
Domestic ❑ Irrigation ❑ Fireline
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ (Formerly
TNRCC) regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Reduced Pressure Principle- Detector
P Double Check Valve ❑ Double Check - Detector
❑ Pressure Vacuum Breaker ❑ Spill Resistant Pressure Vacuum Breaker
l�
Manufacturer: wo<�-i � Size:
Model Number: o Serial Number:
Located At: r
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Remarks:
The above is certified to be true at the time of testing. Tester signature:
Test gauge used: Make /Model Apollo 40- 200 -TK5U SN:_01111194 Calibration ate:_6/10/2013
Firm Name: .01 Accuracy Backflow Certified Tester (print): Terry Sitgreaves
Firm Address: 9990 Barton Circle, Frisco TX 75035 Cert. Tester No. BP0014573 Exp. Date 6/12/15
Firm Phone #: 972.699.7156 Test Date 5-/6-Q
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
Air Inlet
Check Valve
1S check
2 nd check
Relief Valve
Opened at psid
Held at psid
Initial Test
Held a !` psid
Held at .1,d psid
Opened at _psid
Did not open El
Leaked 11
Closed Tight
Closed Tight
Did not open ❑
Leaked
Leaked ❑
Repairs and
Materials
Used
Test after
Held at psid
Held at psid
Opened at _psid
Opened at _psid
Held at psid
Repair
I
I Closed Tight El
Remarks:
The above is certified to be true at the time of testing. Tester signature:
Test gauge used: Make /Model Apollo 40- 200 -TK5U SN:_01111194 Calibration ate:_6/10/2013
Firm Name: .01 Accuracy Backflow Certified Tester (print): Terry Sitgreaves
Firm Address: 9990 Barton Circle, Frisco TX 75035 Cert. Tester No. BP0014573 Exp. Date 6/12/15
Firm Phone #: 972.699.7156 Test Date 5-/6-Q
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
**USE ONLY MANUFACTURER'S REPLACEMENT PARTS