2012_0612 (8)CIIECK ONE:
IRRIGATION
DOMESTIC X FIRELINE
BACT�Z.OW PREVENTION ASSEI4IBLY TEST AND C� REPORT
NAME OF PWS_
PWS LD. #
CITY OF C�PPELL
The bacl-ilaw preveoRion assembly detailed below hss been testod and maiteraizeed as inquired by TNRCC
rn_aulatioos sod is certified to be opeaating within acceptabIc paranxrers_
TYPE OF ASSEMBLY
t= Reduced Presssa+c Principle c Pressiae Vacatum Bt+esira
'� Double Check Valvc D Atmospberz Vacuimm Bteaka
Tvfaaufacttarer (/ Ya � •� Sint 2 r �
Model Nutober /��7� � Located At �. C�/��i � r
SerialNimmber `�7 ����
Date last accuracy tested
White - Customer's Copy Yellow -City Copy PinK - Tester`s Copy
REDi10ED PRESSiJRE PRiNCTPLE ASSE1rIBLY
PRESSiTRE VACLJLJM BREAKER
Doubic Chree3c Valve Assembly
lst Check
2nd Check
Relief Valve
Air Inlet
C� Valve
Initial Test
DC- Closed � � (P
Closed Tight �.
Opened ai
Opmed at
nsid
Tight
Leafed o
nsid
osid
RP- tnid
I.caiad a
,
� �
Did toot Opca o
L.esiaod �
Rzpairs
and
MacaiaLs
Used
Test ASer
DC- Closed
Closed Tight o
Opeood at
Opened at
�sid
Repair
Tight o
t�sid
osid
RP
The above is cadSed to be true
Firm Name ,Tl���n�� �f2� r�� CatiSed Testa �,- �u �-r �STO.rJ
Firm Addtrss �%�.-yC �'� (d,�/aXCtGrQCii �' Cert. Tester No_�f��llY��% Dace
--max
Gauge # [��� � oo �S
Date last accuracy tested
White - Customer's Copy Yellow -City Copy PinK - Tester`s Copy