HomeMy WebLinkAboutPLBG2020-0733Texas Commission on Environmental Quality
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
The following form must be completed for each assembl tested. A signed and dated original must be submitted to the public water supplier for recordkeeping *purposes:
I NAME OF PWS: CLL' v �co—�
I PWS ID#: oC
PWS MAILING ADDRESS: ` PWS CONTACT PERSON: C
ADDRESS OF SERVICE: KCC� es � �- , Lbcmneil✓1&. Ae
The backflow prevention assembly detailed belola
tested and maintained as required by commission regulations
and is certified to be operating within acceptable parameters.
TYPE OF BACKFLOW PREVENTION ASSEMBLY (BPA):
❑ Reduced Pressure Principle (RPBA) 1.0 I Reduced Pressure Principle -Detector (RPBA-D) Type II
(MI Double Check Valve (DCVA) ,❑ Double Check -Detector (DCVA-D) Type II'❑I
❑ Pressure Vacuum Breaker (PVB) ❑ Spill -Resistant Pressure Vacuum Breaker (SVB) 1
Manufacturer: Main:,_, �js5 Bypass: Size: Main: / If Bypass:,
Model Number: Main: Bypass: BPA Location: Fri V, s�`aI►� vtCQe�
Serial Number: I Main:�J �3/44?& Bypass: BPA Serves:
V
Reason for test: I New ❑ I Existing ;, Replacement ❑ Old Model/Serial #
Is the assembly installed in accordance with manu acturer recommendations and/or local codes? CK Yes ❑ No
Is the assembly installed on a non -potable water supply (auxiliary)? ❑ Yes Xi No
TEST RESULT
PASS 0
FAIL ❑
Type II
Reduced Pressure Principle Assembly (RPBA) Assembly
1" Check
Initial Test Held at (.!g psid
Date: /0�40VI Closed Tight 29
Time:)3://p Leaked ❑
FRepairs and
Materials
Used**
Test After
IRe air
Date:
Time:
*** 2ad check: numericreading required for DCVA one
NDifferential pressure gauge used: Potable: I Non -Potable: ❑
Make/Model: JeI2-0a -,— J� SN: �rj Date tested for accuracy
Remarks: -- _ —_ - -- --- _ ———�
I 1
Company Name: R. Licensed Tester Name
(J / /�� Q� (Print/Type): '
Company Address: 026°0 PQ./)ek Tr(• Licensed Tester Name (Signature):
Roexa)a ((, x- {
Company Phone #: _ BPAT License #
47o2}(ov�(o 5�35 I License Expiration Dater
The above is certified to be true at the time of testing.
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS (30 TAC §290.46(B)]
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
Main:
Bypass:
DCVA
-' Relief Valve Bypass Check
2ad Check***
!Held at4g psid Opened at _ Held at _ psid
Closed Tight 1Z psid Closed Tight ❑
Did not
Leaked ❑ Leaked ❑
open ❑
PVB & SVB
Air Inlet Check Valve
Opened at _ psid Held at -7
Did not open ❑ psid
Did it fully open Leaked ❑'
(Yes ❑ /No'❑)
Held at _ psid 11 Held at _ psid
Closed Tight 011CIosed Tight ❑
Held at psid Opened at psid Held at
Closed psid
Tight ❑
2,
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FINAL CHECK LIST
SATE:
PERMIT#:o - b73 3 ADDRESS: Y �1K_ �VO-!� f I-GiYI.0
FINAL WALK THROUGH TO EXPLAIN THE OPERATION OF THE SYSTEM
MAINTENANCE CHECK LIST:
A. THE MANUFACTURER'S MANUAL FOR THE AUTOMATIC CONTROLLER
B. A SEASONAL (SPRING, SUMMER, FALL, WINTER) WATERING SCHEDULE
C. A LIST OF COMPONENTS THAT REQUIRE MAINTANANCE AND RECOMMENDED
FREQUENCY FOR SERVICE.
#_ CHECK AND CLEAN NOZZLE'S MONTHLY FOR CORRECT COVERAGE
=2 TEST RAIN/FREEZE SENSOR EVERY MONTH
=3 SERVICE AND CLEAN Y STRAINER YEARLY
3. THIS IRRIGATION SYSTEM HAS BEEN iNSTALLED IN ACCORDANCE WITH ALL APPUCABLE
STATE AND LOCAL LAWS, ORDINANCES, RULES, REGULATIONS OR ORDERS, ? HAVE
TESTED THE SYSTEM AND DETERMINED THAT iS HAS BEEN INSTALLED ACCORDING TO
THE IRRIGATION PLAN AND 15 PROPERLY ADIUSTED FOR THE EFFICIENT OF WATER AT
THIS TIME
?. PERMANENT STICKER: COMPANY AND WARRANTY DA T ES
5. IRRIGATION PLAN TO OWNER
OW.'ER OR OWNER'S REPRESEfi ATIVE
MID -CITIES IRRIGATION, INL`. REPRESENTATIVE