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2013_0122 (4)
CHECK ONE: IRRIGATION DOMESTIC FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: PWS I.D. # CITY OF CPPELL LOCATION OF SERVICE: The backflow prevention assembly detailed below has been tested and maintained as required by TNRCC regulations and is certified to be operating within acceptable parameters. Reduced Pressure Principle Double Check Valve Manufacturer o e, Model Number serial Number 1 G t C40 TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker Size Located At The above is certified to be true. Firm Name 41' c �ac7s c�k Firm Address y�� Q2., rc�' • �S ©� (o Gauge # 3 -7,9 3 5-3 Date last accuracy tested / •� a ° /3 JUM BREAKER Check Valve osid Leaked ❑ nsid Flea 4 _1, saw-M, N � - � " W-00 wa- � 1-1 Cat. Testy No.8 &61e) 773 Date 9 S`' i 3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACI Double Check Valve Assembly 1st Check 2nd Check Relief Valve Air Inlet Initial Test C55 DC- Closed Tight 1� RP-sid Leaked ❑ Closed Tight I Leaked C3 4- C) Opened at nsid Opened at osid Did not Open ❑ Reps and Materials Used Test After Repair DC- Closed Tight ❑ Closed Tight ❑ Opened at vsid Opened at osid RP sid The above is certified to be true. Firm Name 41' c �ac7s c�k Firm Address y�� Q2., rc�' • �S ©� (o Gauge # 3 -7,9 3 5-3 Date last accuracy tested / •� a ° /3 JUM BREAKER Check Valve osid Leaked ❑ nsid Flea 4 _1, saw-M, N � - � " W-00 wa- � 1-1 Cat. Testy No.8 &61e) 773 Date 9 S`' i 3 White - Customer's Copy Yellow - City Copy Pink - Tester's Copy