2015_0220 C�IECK ONE:
IR.RIGATION V DOMESTIC FIRELINE
�
BACKFT�OW PREVENTION ASSEMBLY TEST AND MAIIVTENANCE REPORT'
NAME OF PWS: CITY OF CIpPPELL
, � �
PWS I.D. #
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LOCATION OF SERVICE� �8y �C�a L�s
The baci�low preveation asscmbly derailed below has beea tested aad maintained as required bv 'I'NRCC
re_suladons and is certified to bc operating within acceptable parameters.
TYPE OF ASSEMBLY
C Reduced Pressure Principle C Pressure Vacu�mm Breaker
� Double Chcck Valve ❑ Atmosphere Vacuum Breal:er
Maaufacuaer �3 c.a Sizc 3�� ��
Model Number g �� Located At �7�Z��
Serial Nimmber l-}C �1 '� !g�j
REDUCED PRESSURE PItINCIPLE ASSEMBLY PRESSURE VACULTM BREAI�R
Doubie Check v alve Assembly +
lst Check 2nd Checl: ��{Valve Air Inlet Check Valve
Initial Test DGClosed Z'2' Closed Tight Opened at Opeaed at osid
Ti�t �. Leal:ed ❑ Dsid nsid
RP-._._psid
�� ❑ Did not Opea � Leal:ed �
�P�
and
Mataials
Usod
Test ARer DC-Closed Closed Tight o ppeaed at Opmod at �sid
Repair Tight ❑ osid osid
RP sid
The above is cextified to be�ue•
Firm N�--�-r �`�� w 5 � ��.t" Cerdfiod Testa �wi . v�..c GI,1
Z "�'� �� � Cat T�r� Date
Fiim Address °ZZ Y La -/S
� �2�.'�':;1�`• .a�� ,4^. ,
Gauge # r I �1 0`�'� ,
llate last accuracy tested /- Z 7—/S
White- Customer's Copy Yellow- City Copy Pink-Tester's Copy