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2011_1216_RPZ
CHECK ONE: IRRIGATION DOMESTIC '11� FIRELINE BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT NAME OF PWS: CITY OF CPPELL PWS I.D. LOCATION OF SERVICE: %J�� ! Ji!!!n 10,a 4� 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. Reduced Pressure Principle ❑ Double Check Valve Manufacturer W a l- 1 S Model Number MQ2 I � SerialNunber .. TYPE OF ASSEMBLY ❑ Pressure Vacuum Breaker ❑ Atmosphere Vacuum Breaker ff Size f 2 Located At S b v The above is certified to be true. Firm Name A►r I g-i- Certified Tester e"a n Firm Address 7(0 Z�ert. Tester No. 0 /3-5q W- Gauge # ©(o / / O() i'0 9 Date last accuracy tested $ -r l White - Customer's Copy Yellow - City Copy Pink - Tester's Copy PRESSURE VACUUM BREAKER REDUCED PRESSURE PRINCIPLE ASSEMBLY Double Check Valve Assembly 1st Check 2nd Check Relief Valve Air Inlet Check Valve Initial Test �S DC- Closed Tight % RP -sid Leaked ❑ Closed Tight )� Leaked C3 g .a Opened at . ��Sid Opened at nSid Did not Open ❑ nsid Leaked ❑ Reps and Materials Used Test ARer Repair DC- Closed Tight ❑ Closed Tight ❑ Opened at nSid Opened at �vSid _,_ osid RP sid The above is certified to be true. Firm Name A►r I g-i- Certified Tester e"a n Firm Address 7(0 Z�ert. Tester No. 0 /3-5q W- Gauge # ©(o / / O() i'0 9 Date last accuracy tested $ -r l White - Customer's Copy Yellow - City Copy Pink - Tester's Copy