HomeMy WebLinkAboutPLIRR2026-000412Texas Commission (•in Environmental Quality
RACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
11R�W�Li:jbrrn mut be wmj4eted for each amembl,.tesied- A si,=d and dated orWrid musL bc subirdited-to the -iblic water m-lier for recorikcr., tne *,u, -vs=
NAME OF FWS: Gracevine
ijiWS ID#.-
PWS MAILING ADDRES
"VWS 60NT�CT PERSON: BaCUM IPPP411)4190F
-60 SERVICE-
AI)Dk6§S
The backflow povention assembly detailed below has been tested and maintained as required by comnussion regulations
and is certified to be ojAradhin acceptable P .. . ...... .
TYPE OF BACKFLOW PREVENTION ASSPOLY
Q Reduced 1:1renure Principle -Detector (RPBA-D) Type-, ff T3
Doubi-hecii Valve (DCVA) i:O j Dotible Cbeck-Detector (DCVA-D) Type
r]l Pressure Vacuum Breaker (PVB) �rl Spill -Resistant Pressure Vacuum BreakeT (SVB)
Ma1iuf4c1lrer
ModelNurnber. Main:
��al Number. M ain:
PERMIT NUMBER: -
Rypams�l
13 SSi.
Size- Mzin: Bypaw-
BPA Location:
13PA Serves:
-Reason for test -7—Ne-w Existing D Replacement jq'.OIdMo&1/Seri0#'
the assembly installed in accordmce with manufacturer recommnidations and/or local codes? es jO.No
Is the assembly installed on a non -potable water supply (auxiliary)? ioly&s !ElNo
TEST RESULT Type 11
Reduced ure Principle Assembly WBA) Assembly PVB & SVB
PAS� DCVAq ..
Relief Vave Bypass Check Air Inlet Check Valve
FAIL I- Check 1, 20d Check*'P*
'd -q edat
Id -7',Lp� Holdat r Held at ��l p6q;j Opcned at psid. Held at i
i1nWid Tat i i psid
�Daw: 7�--z6 ! psid
Closed Tight Tight pClosrd Tight ;E] 1,� Did notopen JEJ
ITime : IDid not !i Did it ftilly 0�m Leak6d
A.� r'm Lcakw Leaked
Lwkcd
open IN a
(Yes(
[R2epairs and i'
I)Waterials
1: l
Usedft !'*pass;
id J Held at
Held at d�Heldat�
Test Aftex Held at L-j psidl
psid Opened at Opened at', pf
Psi
psid liClosed Tsid
,Closed Tigh, Ell
EY,, Closed Tight
not
20d 6eck
numeficreading-req dfor DCVAonI%,
Diii6ential piesiure'gauge used: :: Potable: i Non -Potable:
—kefflodel- SN: 821 0� 15 Date tested fbr accuracv 12, 1,5
Remarks.
2
i
Company: Name, Licensed Tester Nam
Inc.(PrintlT o):
h C Y
Licensed Tester Nam (Signature): OMPPAddress-' '-"'Xl ct�,Rd ol, ,
CompanyPhone -BPAT License
License Ex� iration Date, CIVI),P '"I
The we is certified to be tme at the time of testing.
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TA C §290A6(B)l
USE OnY MANUFACT MR-S REPLACEMENT -PARTS
TCEQ-20700 (Revision 04-04-2019) Page 1 of I