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HomeMy WebLinkAboutPLIRR2029-5007Texas 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 "pumoses: I NAME OF PWS: I r.. I PWS [D#: 3 I PWS MAILING ADDRESS:�G PWS CONTACT PERSON: _ p ADDRESS OF SERVICE: The backflow, prevention assembly detailed below has been tested and maintained as required by commission regulations and is certified to be operating within acceptable parameters. I TYPE OF BACKFLOW PREVENTION ASSEMBLY (BPA): 1 '❑ Reduced Pressure Principle (RPBA) ❑ Reduced Pressure Principle -Detector (RPBA-D) Type IIl❑ 'N Double Check Valve (DCVA) ❑ Double Check -Detector (DCVA-D) Type H ❑' I❑'i I Pressure Vacuum Breaker (PVB) ❑ Spill -Resistant Pressure Vacuum Breaker (SVB) I Manufacturer: Main: Bypass: Size: Main: 'z Bypass: I Model Number: Main: Bypass: BPA Location: IP�%awl y4ird � Ir-,&- 5;.� _ Serial Number: Main: t9 797 % Bypass: BPA Serves: .I S c: �rt pvt Vv 1 Reason for test: I New ❑ I Existing 0 I Replacement ❑ Old Model/Serial # Is the assembly installed in accordance with manufacturer recommendations and/or local codes? %Yes ❑I No Is the assembly installed on a non -potable water supply (auxiliary)? ❑ Yes KNo TEST RESULT' Type II Reduced Pressure Principle Assembly (RPBA) Assembly PVB & SVB PASS DCVA I Relief Valve Bypass Check Air Inlet Check Valve FAIL ❑ 151 Check 2' Check*** Initial Test !iHeld atolpsid Held ato2.psid Opened at _ Held at psid Opened at psid Held at Date: /©� lo2�e-l"Closed Tight ® Closed Tight El psid _ Closed Tight ❑ _ Did not open ❑ psid Time: / 7 :/ a2 1 Did not Leaked ❑ Leaked ❑ Leaked ❑ Did it fully open Leaked ❑ open ❑ (Yes ❑ /No ❑) Repairs and Main: Materials Used** Bypass: Test After Held at _ psid Held at _ psid Opened at _ Held at psid Opened at _ psid Held at Repair Closed Tight ❑ Closed Tight ❑ psid Closed psid D me. Tight ❑ _ *** 2nd check: numeric reading required for DCVA only Differential pressure gauge used: Potable: ,9 Non -Potable: El S/oo`ej0 Date tested for accuracy Remarks: I I I Company Name: J� �/� /� Licensed Tester Name K /gam lc��'uQn (Print/Type): Company Address: "%�/ Licensed Tester Name (Signature): 4 Kks�Olk%� Z Company Phone #: BPAT License # TZj -�0235 License Expiration Date: v:,Pz aj 1 The above is certified to be true at the time oft sd ting. * TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TAC §290.46(B)] ** USE ONLY MANUFACTURER'S REPLACEMENT PARTS