2013_0927 (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 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.
c Reduced Pressure Principle
a�/ Double Check Valve
Manufacturer rimes
Serial Number 0379'
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
C Atmosphere Vacuum Breaker
size /h/
Located At 1 t s r groin A
The above is certified to be true.
Firm Name rre ife,(�a�etit Cimer_I fG
Firm Address age i Ll, G.los Nud'I Euless
7k 7&ogo
Gauge # %Z / 1 & 3,�; 1
Date last accuracy tested 3-S-/3
certified Tester 1,, J kyn4 s
Cent Testa No. APON79.5 Date 127-1
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
Initial Test
DC- Closed
Tie& d
Closed Tight i
Leaked ❑
Opened at
osid
Opened at
nsid
nsid
S
RP- 1, 7 nsid
Leaked ❑
,
Did not Open C3
Leaked C3
Reps
and
Materials
Used
Test After
Repair
DC- Closed
Tight ❑
Closed Tight ❑
Opened at
psid
Opened at
osid
nsid
RP sid
The above is certified to be true.
Firm Name rre ife,(�a�etit Cimer_I fG
Firm Address age i Ll, G.los Nud'I Euless
7k 7&ogo
Gauge # %Z / 1 & 3,�; 1
Date last accuracy tested 3-S-/3
certified Tester 1,, J kyn4 s
Cent Testa No. APON79.5 Date 127-1
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy