HomeMy WebLinkAboutPLIRR2026-000075BACKFLOW PREVENTION ASSEMBLYTEST AND NIAINTENANCE REPORT
The followin, form mjs� Ke,�ormIcted foreach assomb! los'%�cL A ��i � �ed aw) i.tibhc w.itcr su;,micr fcir ocos:
NAME OF PWS.-
PWS ID#.-
--
PWS MAILING ADDRES,S: 5,0,1 Shady Bfo;�K
PWS CONTACTPERSON:
Backfiow Coordinator
ADDRESS OF SERVICE:
The back -flow prevention assemr ly det*etfled below has been tested and rnaintaincd Lis rclqi7red by comm6ssion regulations
and is certified to tie oneratim, witbin accelliable parameters.
TYPE OF BACKFLOW PREVENTION ASSY (BPA):
E]educed Pressure Principle (RP13A) Reduced Pressure Principle -Detector (RPBA-D) Type it U
Double Check Valve (DCVA) Double Check -Detector (DCVA-D) Type 11
Pressure Vacuum Weaker (PVB) Spill- ReNistan t Pressure Vacuum Breals,:r (SV.B)
Main:
Manufacturer. By Bypass: ypass-
Main: tr�P Bypa.qs.4. BPA Location: Model Number-,
Serial, Number- M'�aa' Byj;ass_?
SPA Serves.
P E R M I T N U M B E R
Reason for test: New Existing i' Replacement OjdModel/Scrial4i�'Idjorl
Is the assembly installed in accordance with manufacturer recommendations at local cod s? 'es l�rr
Is the assembly installed on a no� �poabte water supply (auxiliary)?
TEST R E STILT` Ty e �iii
Reduced Pressure Principle Assembly. (RPBA) LAssembly
FAIL 0 1 - Check 11 2"' Check***
Initial Test ;Held atheb_ psid Held at-
psid
Date: I &ON4 losed7fight IT, ClosedTizht
Time: Leaked 0 Leaked
Relief Valve
Opened at —
Bypass Check
Air Inlet
Check Valve
Held at, — psid
Opened at psid
Held at
psid
Closed Tight
Did not open
psid
Did not
Leaked
Did it fully open
leaked �
Open 0
(Yes TI /No EI)
Repairs and ain:
Materials �T',
Used" Bypass:
Test After Held at psid Held at
zr psid Held at psid 'Opened at Held psid Opened -at
Closed Tight 0' Closed Tight Ps i IJ Closed psid
Date:
Tight 1J_
Te:
L
2111 check: numeric re dim! ret, aired for DC VA only
Potable: "J'Non-Potable: C1
Differential pressure ;a c used.
Make/Model: Date tested for accurac%
_ '_L!nz:4
Remarks:
Company Name: Licensed Tester Name
(Prmt/T\Te)-
Company Address: Licensed Tester Name (Signature.) -
Company Phone #: BRAT License :7 YW
00"2a License Expiration Date:
The above is certified to be true at the time of testing.
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TAC k290.46(B)l
(!Sf-, ONLY MANUFACTURER'S RFPl,ACEMFNT PARTS
TCEQ-20700 (Revision 04-04-2019) Page 1 of 1