2014_0131_RPZCIIECK ONE:
IRRIGATION
.a
DOMESTIC
`" FIRELINE
BACIOLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
NAME OF PWS:
PWS I.D. #
CITY OF CPPELL
LOCATION OF SERVICE: "D7:7 kee —AoT A- fV j
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 wd: j
Model Number d c
Serial Number• i
TYPE OF ASSEMBLY
❑ Pressure Vacuum Breaker
❑ Atmosphere Vacuum Breaker
Size III
Located At ` i4 -L'kk C'C SS' r1 �> o
The above is certified to be true.
Firm Name 91 w%,d Y &-,4W 0
Firm Address g9fib & A) C' f'
f r: 54b -PIC 75tis s'
Gauge # 0 l k%q q
Date last accuracy tested
White - Customer's Copy
Certified Tester /err y
Cert. Tester No. M -64.11 Vs--73 Date -3i
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
Tight ❑
RP- 3i . sid
Closed Tight .ltd
Leaked IC y ❑
Opened at
..psid
Opened at
osid
osid
Leaked ❑
Did not Open ❑
Leaked ❑
Reps
and
Materials
Used
Test After
DC- Closed
Closed Tight ❑
Opened at
Opened at
,___--- nsid
Repair
Tight ❑
osid
osid
RP sid
The above is certified to be true.
Firm Name 91 w%,d Y &-,4W 0
Firm Address g9fib & A) C' f'
f r: 54b -PIC 75tis s'
Gauge # 0 l k%q q
Date last accuracy tested
White - Customer's Copy
Certified Tester /err y
Cert. Tester No. M -64.11 Vs--73 Date -3i
Yellow - City Copy
Pink - Tester's Copy