2011_1209CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE �„�`"�
BACKFLOW PREVENTION ASSEA�LY TEST AND MAINTENANCE REPORT
NAME OF PWS: CITY OF CgPPELL
PWS I.D. #
LOCATION OF SERVICE:
The bacldlow prevmtioa assembly detailed below has bcea tested and ma;„ ;*+ed as required by TNRCC
regulations and is certified to be operating within aeeeptable parameters_
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacuinn Breaker
C ' Double Chxk VaIvc C Atmosphere Vacuum Breaker
Manufacturer SiZC -
Model Number
Serial Number
Located At
The above is certified to be true.
Firm Name
Fitm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACI.TiJM BFLEA�R
Double Check Valve Assembly
1st Check
2nd Checl:
Relief Valve
Air Inlet
Chec3c Valve
Initial Test
DC- Closed
Ti_Qhi o
Closed Tight o
Leaked Q"
.Opined at
vsid
Opined at
osid
osid
RP- vsid
Leaked ca�'
" -
Did not Open O
Leaked o
Rcpatrs
and
Matcials
Used
Test Alts
Repair
DC- Closed
Tight o
Closed Tight o
Opined at
osid
Opened at
osid
osid
RP sid
The above is certified to be true.
Firm Name
Fitm Address
Gauge #
Date last accuracy tested
Certified Tester
Cent_ Testa No.
Date
White - Customer's Copy Yellow -City Copy Pink - Tester`s Copy