2013_0906 (15)CIIECK ONE:
IRRIGATION DOMESTIC FIRELINE
BAGGLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF CPPELL
LOCATION OF SERVICE:
The back-flow prevention assembly detailed below has been tested and maintained as required by TNRCC
regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
❑ Reduced Pressure Principle ❑ Pressure Vacuum Breaker
❑ Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer Size
Model Number rt�l„ Located At .;Y� SC Y Y�.>
Serial Number r24
The above is certified to be true.
Firm Namef�
Firm Address / 07Gc4le LAh
Gauge #"l!
Date last accuracy tested
Certified Testa% i
Cat. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Check Valve
Ininal Test
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Tight
RP - �// 9 psid
Leaked ❑
Leaked ❑
f y
Dsid
osid
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
nsid
Repair
Tight ❑
psid
nsid
RP sid
The above is certified to be true.
Firm Namef�
Firm Address / 07Gc4le LAh
Gauge #"l!
Date last accuracy tested
Certified Testa% i
Cat. Testa No. Date
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy