HomeMy WebLinkAboutPLBG2022-002383Texas Commission on Environmental Quality
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Thp followin� form miust be completed for each assernbl, tested- A sivied and dated ori,7nal must be submitted to the public water su�q,lier for recordke,--oin-, 'I v roses:
NAME OF PWS:•
PWS ID#: ZZ000 I
PWS MAILING ADDRESS:
��" Aio� 0
Pws CONTACT PERSON: jb�K,.KFI—G C 00 V—D"Al 0 rZ—
MAC& C01e'"t7g- STOal "IV1,%0"K-V1Ne,TX`140q
The backflow prevention assembly detailed below has been tested and maintained as required by commission regulations
and is certified to be oi,eratin,2. within acceptable parameters.
TYPE OF BACKELOW PREVENTION ASSEMBLY (BPA):
Reduced Pressure Principle (RPBA) 0 Reduced Pressure Principle -Detector (RPBA-D) Type, II:0
Double Check Valve (DCVA) ■ Double Check -Detector (DCVA-D) Type 11
Pressure Vacuum Breaker (PVB) Spill -Resistant Pressure Vacuum Breaker (SVB)
Manufacturer: Main:' VIJPMS Byp
as Size: Main:'! Bypass:
Model Number: 1 Main: !:L�r_0Cj_,j 0-T Bypass BPA Location: KCkc- t-- 1-T CtIeN
BPA Serve Serial Number: 1 Main: 2,:�AW C) I Bypqss�
i Replacement Old Model/Serial
Reasonfortest: New Existing '0:
u .2kYes 11 No
Is the assembly installed in accordance with man facturer recommendations and/or local codes?
Is the assembly installed on a non -potable water supply (auxiliary)? i� 0 Yes I&No
PVB i B
;_r4
Held psidl I'Jeld at:-1.2.psid bpened . t. r Opened at psi Held at
Ppsid
Closed Tight -& �&sed Tight !91 Did not open psid
iiDid not
Leaked 'ked El' Did it fully open Leaked
1�open
(Yes /No
Repairs and Main:
Materials
Used" Bypass:
Tes
paid Opened at i paid _ Held at
Opened a Held at t After Held at psid' Held at 'paid g t
BM —ai r. i Closed Tight O'Closed Tight ;E] kIpsid Closed psid
Date: Tight
Time:
2,d check: numeric reading its uired for DCVA on1v
" Differential pressure gauge used: Potable: Non -Potable:
Make/Model: Ill ate tested for accurac 1 Z-L SN
RemarkS.
Company Name: f Licensed Tester Name
(Print/T\,ne):
Company Address: GS JS pove CLicensed Tester Name (Signature):
Company Phone#: BPAT License# P>P 00 0 1SW
License Expiration Date:
The above is certified to be true at the time of testing.
TEST RECORDS MUST BE KEP`r FOR AT LEAST THREE YEARS [30 TAC §290.46(B)l
** USE ONLY MANUFA REPLACEMENT PARTS