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2013_0702City 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 Desiree Pianelli 0 sidentia e ommercial Address of Assembly: 635 Lake Park Dr. ❑ Domestic 19 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 l r Double Check Valve ❑ Double Check - Detector ❑ Pressure Vacuum Breaker ❑ Spill Resistant Pressure Vacuum Breaker �I Manufacturer: W Size: Model Number: 0��©°° " Q1� Serial Number: Located At: ryu, _(- Is the assembly installed in accordance with manufacturer recommendations and /or local codes? Ile Remarks The above is certified to be true at the time of testing. Tester signature: �f -L— 7 Test gauge used: Make /Model Apollo 40- 200 -TK5U SN 01111194 Calibration Date:-6/10/13 Firm Name: 01 Accuracy Backflow Certified Tester (print): Terry Sitgreaves Firm Address: 9990 Barton Cr., Frisco, TX 75035 Cert. Tester No. BP0014573 Exp. Date-6/12/15 Firm Phone #: 972.699.7156 Test Date 4 % _L_ l j *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS Reduced Pressure Principle ssembly Pressure Vacuum Breaker Double Check Valve Assembly Air Inlet Check Valve 15 check 2" check Relief Valve Opened at psid Held at psid Initial Test Held at psid Held aiZrpsid Opened at_psid Did not open ❑ — Leaked ❑ Closed Tight EY Closed Tight /E 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 ❑ Remarks The above is certified to be true at the time of testing. Tester signature: �f -L— 7 Test gauge used: Make /Model Apollo 40- 200 -TK5U SN 01111194 Calibration Date:-6/10/13 Firm Name: 01 Accuracy Backflow Certified Tester (print): Terry Sitgreaves Firm Address: 9990 Barton Cr., Frisco, TX 75035 Cert. Tester No. BP0014573 Exp. Date-6/12/15 Firm Phone #: 972.699.7156 Test Date 4 % _L_ l j *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS **USE ONLY MANUFACTURER'S REPLACEMENT PARTS