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BACKFLOW PREVENTION ASSEMBLY TEST AND MAEVIENANCE REPORT
�efujlq%jq- fornimust be coml leted for each assembl, teste& A si-ied and dated oriainal mu be,a omitted to the:,ubbe water sularher for recordkee, ins au �-oses:
NAME OF PWS: Gra,evine
PWS ID#:
PWS MAILING ADDRESS:
PWS CONTACT PERSON: Back,flow Co9rdinator
ADDRESS OF SERVICE Steve Toni Adkins (SFD)t 1AQ9 Rolling Ridqe Dr
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.
TYPE OF BACKFLOW PREVENTION ASSEMBLY (BPA):
F Reduced Pressure Principle (RFBA ) 0 Reduced Pressure Principle -Detector (RPBA-D) Type H'
Double Check Valve (DCVA)
Double Check -Detector (DCVA-D)
-Type if!
Pressure Vacuum Breaker (PVB) Spill -Resistant Pressure Vacuum Breaker (SVB)
M M
anufacturer: ain Bypass -
Size: Main: 3/,f Bypass:
Model Number: Main: 4P 30 -ZA4 5 Bypass.4; 1k'Location: j .yt„ ¢F¢
Serial Number: Main:,? -(-I 14f Ir Bypass-`
PERMIT ER: 26-000243
Reason for test: i New X Existing Replacement 0 Old Model/Serial #
Is the assembly installed in accordance with manufacturer recornmeridations and/or local codes?
Wyles No
Is the assembly instalIed on a non -potable water supply (auxiliar y)?
es No
TEST RESULT
Type H
Reduced Pressure Principle Assembly (RPBA) 11 Assembly PVB & SVB
PASS DCVA
- foRelief Valve i Bypass Check lAir Inlet Check Valve
FAIL 11 Is'Check Check
. ..... ....
psid Opened at Held at
Wtial Test Held at psid Hold at; rpsid Opened at Held at'l id I ps
psid Date: Closed Tight 1[ ,ht 0-l'i'Clo,ed Tight $ Closed Tight iO not open psid
Time: 1: Did it fullopen Leaked
ked Leaked
Did not Leaked y
4 Lea'[I a
(yesJ
-- t 1
open 0
Repairs and Main. -
Materials
Used** 'Bypass:
'�Held atL
Test Aft*x Held at psid �,,Held at psid. J Opened at_. psid Opened at psid J Held at,
�psid ;,�,Closed Ipsid
Re air. O','ClosedTight Ui
t7 at
Tight 'El
D _ at
e:
Time: 1
211d check: numeric readingyea-!#Ijekb� DCVAonl%,
0
Differential pressure gauge used- Potable." Non -Potable:
Ntake/Model: �"Owest 845-5 g SN: 12171802 1 Date tested for accurac% 08-18-2025
Name: Co p-,InY N 1.01 Accuracy Backflow Licensed Tester Name 'Michael MaChen
(Prmt(r\;!ie):
Compy Address: x 32
Licensed Tester Name (Signature):
anP0 Bo68
IMcKinney, TX 75071
Company Phone ff: 72--715BPAT License BPOO18647
96996
. ... ... LicenseExpiration Date: 10-17-2027
The above is certified to be true at the time of testing.
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TAC §290.4.6(B)]
USE ONLY MANUFACTURER'S REPLACE ENT PARTS
TCEQ-20700 (Revision 04-04-2019) Page 1 of 1