2014_0515 C�IECK ONE:
IRRIGATION�f_ DOMESTIC FIRELINE
BACT�'LOW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT
NAME OF PWS: CITY OF COPPELL
PWS I.D. #
LOCATION OF SERVICE: '-1 ''�l `� � 1�.f� ��
The bacl�low preveation asscmbly detailed below has beea tested and ID�1nta�*�Cd as required bv TNRCC
rcgularions and is certified to be operatiag within acceptable parameters.
TYPE OF ASSEMBLY
e/` Reduced Pressvre Principle C Pressure Vacuimi Breaker
� Double Chcck Valve o Amiosphere Vacuum Brealcer
Maaufacturer F'E'l��t ��,� Siu
��\
Mode1 Number � `��� Located At �`,k�( \� �\\\�u ;�,:ti����,( �
Serial Nimmber '����i �0��'���e1 � �
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE V�CUUM BREAi�R
Double Check v alve Assembly
ist Check 2ad Checl: Relief Valve Air Inlet Check Valvs
Ininal Test DGClosed Closed Ti�t Opened at Opened at osid
Tisht Leal:ed ❑ nsid _osid
R.P-�psid
�;� ❑ Did not Opca o Leai;ed o
RtPaus
aad
Mataials
Used
Test ARer DC-Closed Closed Tight o Opeaed at Opeaed at _nsid
Repair Tight o �sid osid
RP sid
The above is cerd6ed to be true.
FiimName �.��-,k ,.<�( ;�_�c ,,�r4-��t� CertifiedTatta l��tactti i1� n��,PU
Firm Address ".v�•-� �.. �,�,�r�.� ` ,A, 'F�F�� Cert. Testc No. ����1`��'�>�U Date 1i` �`'
�� ��;��`��
Gauge # ,"��,1,,�,,� , ��
llate last accuracy tested � �
White- Customer's Copy Yellow - City Copy Pink-Tester's Copy
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