2013_0126_RPZ (3)City 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
dame 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 Med Tech (Kelly) 469.688.4489 RoS3 ❑ Residential x Commercial
Address of Assembly: 143 S. Denton Tap Rd., Ste. 180 ["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
It Reduced Pressure Principle ❑ Reduced Pressure Principle- Detector
• Double Check Valve ❑ Double Check- Detector
• Pressure Vacuum Breaker ❑ Spill Resistant Pressure Vacuum Breaker
Manufacturer: W 14+j
Size:
Model Number: 013 1 u Serial Number:
Located At: L -A Pk o J A\
Is the assembly installed in accordance with manufacturer recommendations and /or local codes? Y
Remarks:
The above is certified to be true at the time of testing. Tester signature: dl„NI ,lam
Test gauge used: Make /Model Apollo 40- 200 -TK5U SN 01111194 Cali Oration Date:_6/26/12
Firm Name: 01 Accuracy Backflow Certified Tester (print): Terry Sitgreaves
Firm Address: 9990 Barton Cr., Frisco, TX 75035 Cert. Tester No. BP0014573 Exp. Date
Firm Phone #: 972.699.7156 Test Date ri - Z G -13
*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
1 s' check
2" check
Relief Valve
Open d at _psid
Held at psid
Initial Test
Held at psid
Held at JXpsid
Opened ate psid
Did not open ❑
Leaked ❑
Closed Tight
Closed Tight Iff
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
Closed Tight ❑
Remarks:
The above is certified to be true at the time of testing. Tester signature: dl„NI ,lam
Test gauge used: Make /Model Apollo 40- 200 -TK5U SN 01111194 Cali Oration Date:_6/26/12
Firm Name: 01 Accuracy Backflow Certified Tester (print): Terry Sitgreaves
Firm Address: 9990 Barton Cr., Frisco, TX 75035 Cert. Tester No. BP0014573 Exp. Date
Firm Phone #: 972.699.7156 Test Date ri - Z G -13
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
* *USE ONLY MANUFACTURER'S REPLACEMENT PARTS