2014_0128 (2)CIIECK ONE:
IRRIGATION fir/ DOMESTIC FIRELINE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF CPPELL
LOCATION OF SERVICE:t� z y i (1 G r CA co F !P t✓�-i. I X= C t
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 C Pressure Vacuum Breaker
Double Check Valve ❑ Atmosphere Vacuum Breaker
Manufacturer ��`� L Size
3/ it
Model Number Located At C&V, L"gg
Serial Number 3
The above is certified to be true.
TUM BREAKER
Firm Name �(W Ei► �r i. q Certified Tester i v � A. (A c Kam'-' s
Firm Address 1A 13 Owe-as o'er . C- c-:;.. �r %Cert Tester No.INT0004 Date
.1 GC%,
Gauge # l u, C) g } � QW t( 5 %-i- ; - C
Date last accuracy tested �f -.3 () " 13
Check Valve
nSid
Leaked ❑
nSid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE V-A-CI
Double Check Valve Assembly
1st Check
2nd Check
Relief Valve
Air Inlet
Initial Test
DC- Closed ,2,
losed Tights Vr
Opened at
Opened at
Tight &11
RP -_psid
Leaked ❑
nsid
nSid
Leaked ❑
Did not Open ❑
Repairs
and
Materials
N V C
n e-
Used
Test ARet
DC- Closed
Closed Tight ❑
Opened at
Opened at
Repair
Tight ❑
nSid
vSid
RP sid
The above is certified to be true.
TUM BREAKER
Firm Name �(W Ei► �r i. q Certified Tester i v � A. (A c Kam'-' s
Firm Address 1A 13 Owe-as o'er . C- c-:;.. �r %Cert Tester No.INT0004 Date
.1 GC%,
Gauge # l u, C) g } � QW t( 5 %-i- ; - C
Date last accuracy tested �f -.3 () " 13
Check Valve
nSid
Leaked ❑
nSid
White - Customer's Copy Yellow - City Copy Pink - Tester's Copy