2015_0707 C�IBCK ONB:
IRBIGATION DOMESTIC !f FIRELINE
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��.,,� BAC'I�LOW PREVENTION AS5EMBLY TEST ANb MAINI'ENANCE REPORT
NAME OF PWS: C�C'p��I �- S �[.� �1 �"}��� C�
PWS I.D.#
LOCATION OF SERVICE: � ( �J �S a r^u-e I s
13e bacl�low prevmtion asscmbly decailod below has bau tested aad ma�IItain� � nq� bv TNRCC
regulanons aad is cutified to bc operating withia acceptable paramcters.
TYPE OF ASSEMHLY
,e� Reduced Pressure PrincipIc 0 Pressure Vacuum Breaker
o Double Chcck Valve o Amiosphere Vacuum Breaker
Manufacturer �a�� S Siu � ��Z
Model Number �O ci Located At (�u�S��,�� � �,oS�cc�r'
Serial Ntanber � �� � � � �1'�'a►��
REDUCED PRESSURE PRINCTPLE ASSEMBLY PRESSURE VACULTM BREAI�R
��,. DoubirCheck Valve Assembly .�,.��,.: --
lst Check Znd Checi: Relief Valve :�ir Inlet Check Valve
Inirial Test DC-Closed Closed Ti�ht o Opeaed at Opeaed at osid
Ti�ht Leal:ed o Z �� psid _nsid
���� RP- �_$ psid
L e a l:e d ❑ D i d aot Opea o L e a k e d o
�P�
aad
Materials
Used
Test ARrer DC-Closed Closed Tight o Opeaed at Opeaed at ___nsid
Repair Tight o _,_,�sid nsid
RP sid
The above is catified to be true.
Firm Name �-€a t�P e�1 y S L� Catifiod Yesca � -�a� ��
Firm Address 1�E>3 `� Cat Teste No.���b�� Date r7 � I�
�"� Gauge � 2'�'`'`,��OOO
� ,,� .��
llate last accuracy tested � � 1��
White - Customer's Copy Yellow - City Copy Pink-Tester's Copy