2012_0601CIIECK ONE:
IRRIGATION DOMESTIC
FIRELINE
BACKFLOW PREVENTION ASSE1V18LY TEST AND MAII�l'I'ENANCE REPORT
NAME OF PWS:
CITY OF CC�PPELI_
PWS I_D. # � {�ll � V` 1��✓
LOCATION OF SERVICE: I I2 �� Q�i Z
The baci�low prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
e /Reduced Presstffe Principle
� Double Check Valve
Manufacturer
Model Ntmzber
serial Number - a-1to. 33430
TYPE OF ASSEMBLY
C Pressure Vactn_**n Breaker
o Atmosphere Vacuum Breaker
Size
a� '�
Located At �,(!n �p���� w��
The above is�cer^tified to be true. \ , �` 1
Firm Name I cn%�,��p�!� y Certified Tester � J�'e5G [/ ` ` l l ���i n
Firm Address f/1� �+� � �` -�'�� X- Cent Testa No. �P � U�0 I -1 Dau C9— � � � fi
Gauge # 0 Qa3 �s3 R
Date last accuracy tested 3 -1.lj - 13
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM
B>:t>''ar�'R
Double Check Valve Assembly
1st Cheri:
2nd Checl:
'ef Valve
Air Inlet
Check Valve
Initial Test
DC- Closed
losed Tight
Opened at
Opined at
osid
Tidal �
RP- �,�asid
Leaked 1 0
Z'
osid
osid
ualcd o
Did not Opm a
Leaked '�
RcPa+. -c
and
Materials
Used
Test Alter
DC- Closed
Closed Tight o
Opined at
Opined at
osid
Rapair
Tight �
osid
osid
RP aid
The above is�cer^tified to be true. \ , �` 1
Firm Name I cn%�,��p�!� y Certified Tester � J�'e5G [/ ` ` l l ���i n
Firm Address f/1� �+� � �` -�'�� X- Cent Testa No. �P � U�0 I -1 Dau C9— � � � fi
Gauge # 0 Qa3 �s3 R
Date last accuracy tested 3 -1.lj - 13
White - Customer's Copy Yellow -City Copy Pink - Tester's Copy