HomeMy WebLinkAboutPLBG2026-000443Texas Commission on Environmental Quality
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Ma f
Type 11
Assembly PVB & SVB
ro
Bypass Check Air Inlet Check Valve
M.
ITT-.=
Held at
w
Psid 0 nod at!
Closed Tight [pd Closed
Tight'0
21d check. numeric reading rep for onlv
lerential sure gauge sPotable: Non -Poi e: tkefflodel: 240498 Date tested for accurac�-
.... ......
—ke _marG:
Company Name: Licensed Tester Name
All Star Backflow & Plbg : �: Steven W. Sellar
(PrintTLe):
CompanyA aiisi. 508 Cozby Ave Licensed Tester Name (Signature):
Coppell TX 75019
Company Phone 426 524-9924 BPAT License #
License Expiration Date: i 01/15/2028
The abbve is certilied to be true at the time-4 twqtWg.
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TAC §290.46(B)1
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
TCEQ-20700 (Revision 04-04-2019) Page I of 1
Texas Commission on Environmental Quality
BACKIFLOW PREVENTION ASSEMBLY TEST AND MAWMNANCE REPORT
nefollowin form must be completed for each ammblvtested. A MAW and dated oripinal must be submitted to the water sw-Aier fbr recorJ� n,, in!! *iu, osm:
NAMEOFPWS: Grapevine
PWS ID#:
MXiLiNGAbbRESS: 50.1 Stiady. Brock
PWS CONTACT PERSON:
Backflow Coordinator
'ADDRESS OF SERVICE: 4<
The backflow preventitr... i detailed below has been tested and maintained as required by comnu siion. regulations
and is certified tobe oper,ad,m! within acceptable jarameters.
TYPE OF BACKFLOW PREVENTION ASSEMBLY (BIW;
Reduced Pressure Principle (RPBA) 1 b i Reduced Pressure Principle -Detector (RPBA-D) Type f1101
Double Check Valve (DCVA)
1,13 Double Check -Detector (DCVA-D) Type 11 �0
rf Pressure Vacuum Breaker (PVB) Spill -Resistant Pressure Vacuum Breaker (SVB)
. ...... ....
—Bypass: I Main- Bypass -
Manufacturer Main:' LJA-Tl Size -
Model Number: Main:. Lf�b 13ypass BPA Location: A�eV
qij1!k t
<rjjVA3 Byp.
Z.
Serial Number. Main: aBPA Serves:
PERMIT NUMBER: Z16 06-0 Q 44, "t,
Reason for test: New Existing Replacement 10 OldModel/Seria.1#1 I
Is the assembly installed in accordance with manufacturer recommendations andfor local codes?
[Yes [11 No
. .... .....
Is the assembly instaUed ort a non -potable water supply (auxary)? 1 11 1yes No
TEST RESULTI Typeli il
PV... .m..M...C__.m ..n.B & SVB
A , educed Pressure. Principle Assembly (RPBA.)
PAS 9. DCVA a,
Relief Valve, Bypass Check Air Inlet Check Valve
I" C
2nd Check***
FAIIL heck
"ps
id held at:Held at id, Opened at L
Wtial Test .�psid penedat' psid Held at
Date: 31S2osed Tight ClosedTight I,ice psid Closed Tight;E] Did not open I[j sid
Did not Did it full
open Leaked
Leaked Leaked ILeaked 0
open
(Yes /No
Rep !
Materials
**i ease
Test After Held at psid Held at psid Opimed at Held at psid. Opened atl 1 psid Held at
! at ps 11
lop
Re "ir �Closed Tight 0' Closed Tight bi psid Closed psid
Date- Ir Tight;0
Time: 1
2d check: numeric readin;,. re aiTti for DCVA onl,.r
Differential pressure gauge used: Potable: Non -Potable: 13
Make/Model: -5 _§N: 0M.4240498Datet sted. for accurac
Midwest 84S
..... ..... ......
kS.
C.
(..c),ompany Name: Licensed Tester Namell Star Backflow & Plb 5teven W. Sellr
9
Company Address- 508 Cozy Ave Licensed Tester Name (Signature):
Coppell TX 75019
Company Phone*: 426 524-9924 BPAT License # B.IP001 7029
1 License Expiration Date: a 01/15/2028
The ab6ve is certified to he true at the time of tesft.
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [30 TA C §290.46(B)]
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
TCEQ-20700 (Revision 04-04-2019) Page 1 of 1