2015_0427 C�ifiCK ONE: �
IRRIGATION DOMESTIC FIRELINE
BACI�Z.OW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT ,
NAME OF PWS: CITY OF CC�P.1'�'LL. �
PWS I.D. #
LOCATION OF SERVICE: C� I�; �r.� ''-;>����-�; (. � :
The bacl.�flow prcvention asscmbly detaile� below has bxa tested aad maintained as required by TNRCC
regulazions aad is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
e Reduced Pressure Principle e Pressurc Vacu�Breaker � ,
Doublc Chxk Valve � A�nosphere Vacuum Breaker ;
Manufactiaer t<�CC� Size �/`f '
° Model Number 1��! Locatcd At �.;� � "�'c� < ` '
s«��N�ba !��'1� ��._
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACULIM BREAI�R
Double Check Valve Assembly ,
lst Check 2 Check'` 'ef Valve Air Inlet Check Valve
Initial Test DGClosed , losai Ti;ht �Jpeaed at Opened at esid
Tight �� `�-�'��� Lcal:ed Z � r nsid �osid
����., R.P-_psid -
Lcal;ed o Did not Opar 0 L,eal:ed� �
� RrPairs
,��
aad ,
- . MaE�ials
�.Jsed
Test After DGClosed Closed Ti,ht o Opeaed at Opeaod at _�sid ;
Repair Tight � Dsid osid
RP sid
'I1ie-above is ccrtified be w�:�``' '
Firm Name t tl�'��r� Catified Testa (' �-, ,�'z% '
Firm Address ��(,�'f fi x ��C�''�1�� Cat Tester No. ��'� `�' Date - �
E�,���" �-. �� �?i'�,
�
c3suge # I�I��u�`�
llate last accuracy tested �/--,�� ;�a
White- Customer's Copy Yellow - City Copy Piqk-Tester's Copy