Loading...
HomeMy WebLinkAboutPLIRR2021-3741Texas Commission on Environmental Quality BACKFLOW P VENTION ASSEMBLY TEST AND MAINTENANCE REPORT The followinf form must be comMeted for rrac Wsembla tested, A signed and dated on anal must be submitted to the public water supplier forreeordiceeoina *aumoses: NAME OF PWS: I + PWS ID#: 1 �' ^ PWS MAILING ADDRESS: i V • t3 . Wa0 Er h, 21) 2A- I PWS CONTACT PERSON: i ADDRESS OF SERVICE: I o- ;: 6-4r,,g- Z'119 The backflow prevention assembly detailed below has been testdd and maintained as required yb Commission regulations and is certified to be operating wift,n acceptable parameters. TYP OF BACKFLOW PREVENTION ASSEMBLY (BPA): +p Reduced Pressure Pr(RP inci le BA) I Reduced Pressure Principle -Detector (RPBA-D) Type H I❑i Double Check Valve (D V ) ❑� Double Check Detector (DCVA-D) Type HILT >� Pressure Vacuum Breake (SVB) � Spill -Resistant Pressure Vacuum Breaker (SVB) I Manufacturer: Main: A J Bypass + Size: Main;11 % Bypass:11 Model Number: Main: Bypass. I BPA Location: Serial Number: Main: % % j; Bypass BPA Serves: ` Reason for test: j New 141 Lting Replacement Z Old Model/Serial #1 I Is the assembly installed in acco a ice with manufacturer recommendations and/or local codes? Is the assembly installed on a noni-potable water supply (auxiliary)? TEST RESULT I Type H Reduced Pressuz'p'rinciple Assembly (RPBA) Assembly PASSI rq_ D IIIry i 1` es ❑I, No I��1 ❑ Yes No PVB & SVB ` Relief Valve Bypass Check Air Inlet FAII� ❑' 18t Check 1 2°6 Check*** Initial Test Held at �' sid ld at u )sid `Opened at Lj Held at" sid Openedat"psid Date:: ; ��'ZL ClosedTight osed TightIPsid t1aked Closed TightDidnotopen❑` Time:IDid /ti! oc9�`'► Leaked ❑ ❑ not o en 1❑f P Leaked ❑ Did it fully open (Yes 101 /No 1.0 Repairs and Main:1 I Materials Check Valve Held at psid Leaked �❑ Used** Bypass: Test After Held at" psid L:eld at" psid Opened at u Held at L_j psid Opened at L__j psid Held at Re air Closed Tight �❑1 Closed Tight 10 psid Closed psid Date: Tight p❑I Time: 2 check: nul :eric reading required for DCVA only Differential pressure gauge used: 1 Potable: l Non-Potable:©� Make/Model: 1 hI 1 I SN: I I Q1113di 4 LJ 1 Date tested for accuracy I Remarks: I I Company Name: I Licensed Tester Name (Print/Type): I� CpOh'L.'G7. 1 Company Address: I I 2616 H,,r6 ay Licensed Tester Name (Signature): X V111,2 Ft. worly T Company Phone #: I 1 017 7JG _'Qa7 BPAT License # i �aT- Th(, License Expiration Date: I I 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 R-PLACEMENT PARTS TCEQ-20700 (Revision 04-04-2019) Page I of 1