HomeMy WebLinkAboutLOTDRAINAGE 2026-000530Texas Commission on Environmental Quality
BACEFLOW PREVENTION ASSEMBLY S T
the foliowi fbnn must becormleted_ for esch asscmblvwted. A slued and ed aridnal musibe submitted ta._...._.w.+.blic water su ;Tier for reca , a®a *;,;,,,,'r,tes:
( NAME ,... OF Grmnevine
PWS
i P S MAILINGADDRESS; m i &1:w9y Brook,�
$^�ADDRESSli ; „
P S P Coordinator
The backflow preventionassembly detailed below has been tested and maintained as required by commission regulations
and is certified to be opera ' v within accep- le i.-arameters.
TYPE OF BACKFLOW PREVENTION ASSEMBLY (BPA):
Reduced Pressure Principle A) 0 ReducedPressurePrinciple-Detector (- ) Type If:
j u le C Valve C )
( A Q
ble Check -Detector VA-D) Type I
t Pressure Vacuum Breaker ) Spill -Resistant Pressure Vacuum Breaker (S )
Manufacturer Bypass- ; Size:.. Main- , : 1.
o e2 Number: s Main: Bypassa- APA Location:
al Aluer_ ass,
BPA Serves:
PERMIT NUMBER:
Reason
r test' ReplacementModel/Serialn. tail in accordance with manufacturer eco er tions l
Is the a se; e r codes? E:wl';Yes [ o
Is the assembly is on a non -potable water supply (auxiliary)? T1 Yes No
TEST RESULT Type Il
VI
Reduced Pressure Principle Assembly ( ) Assembly. PV`B & SVB,
` �.. DCVA
Bypass Check .. Air ___...
1 Inlet Check Valve
-... Relief Valve
FAIL
Check 2Ad Check***
_..
Held at T sat Psr+eoa P gpsi"d,.
,at:T _ Fstd el at Opat
at: -
Closed Tight pstdCIF pare tDe not eDid notDid it fully open. kdTimeLeaked
Leaked
open (Yes o'
Repairs d
Materials
Used** }'Pass:
HelTest r Held at sid Held at Tight p SRd Opened at CHeld lo at ... i Opened at psid
osed
a.. 'd at
s
ed
it Closed Tight
Date: l Tight
Ti
numeric ding reps..
:_.:_.. . � check. ' ' aired for D a
nIv
Differential pressure gauge
e 11d
A. .. bee. E�.,..�..... F .a .... ... ... ... ..... ... ,.
,.... . ,, ..... used: Potable: 1 ,Non -Potable:
aic el. SiV Date t for accurac '
e ks:
i
Company Name: r,.' Licensed Tester NameM
Comp y Address Licensed°Tester Name (Signature):
4 ).
Company Pbone BPAT License 4j r
License Expiration Date:
The above is certified, to be true at the tia of
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS (30 TAC §2 ))
** (ISE ONLYMANUFACTURER'SREPLACEMENT PARTS
T 207(Revision 4 2019) Page I of I