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IS THE ASSEMBLY INSTALLED IN ACCORDANCE WITH MANUFACTURES RECOMMENDATION OR LOCAL CODES?
APPROVED By TCEQ on 03/09/2018
White Copy City of McKinney Water Department Yellow Copy Backflow Assembly Tester Pink Copy Customer
_______PSID CLOSED TIGHT
1ST CHECK
HELD TIGHT at ______PSID
LEAKED
CLOSED TIGHT
INITIAL TEST
________________________________
________________________________
________________________________
________________________________
________________________________
CLEANED
REPLACED
REPAIRS:**
GIVE DETAILS of
REPAIRS MADE:
HERE
FINAL TEST
City of McKinney
P.O.BOX 517 McKINNEY, TEXAS 75070
BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT
PERMIT NUMBER
This form MUST be COMPLETED for each assembly tested. A SIGNED and DATED ORIGINAL must be submitted to the Public Water Supplier for Record keeping purposes:
SIZE: _________________________________________ MAKE: ___________________________ MODEL: ____________________ ASSEMBLY LOCATION: _________________________________ BPA SERVES___________________________________________ AUTHORIZATION TO TURN WATER SERVICE OFF: __________________________________ TIME: _______________AM / PM
RESIDENTAL COMMERCIAL RP DC PVB SVB RPDA DCDA
PASS FAIL
LAST DATE GAUGE TESTED FOR
ACCURACY: _____________________ FIRE SPRINKLER: OUTSIDE INSIDE DOMESTIC LAWN SPRINKLER COMMERCIAL
INITIAL TEST
TEST AFTER REPAIR
GAUGE
DOUBLE CHECK VALVE ASSEMBLY
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.
ASSEMBLY
SERIAL NO.
OPENED at _________PSID
RELIEF VALVE OPENED at _________PSID
DID NOT OPEN
LEAKED
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
CLEANED
REPLACED
REDUCED PRESSURE PRINCIPLE ASSEMBLY
NAME OF PUBLIC WATER SYSTEM (PWS): McKINNEY, TEXAS PWS IDENTIFICATION NUMBER: 0430039
PROPERTY OWNER: __________________________________________________________________________________________
Mailing Address: _____________________________________City: _________________________ State: _________ Zip: ________
Contact Person: _______________________________________ PHONE NO: ______________________________________________
Location of Service: _____________________________________________________________________________________________
REASON FOR INSPECTION: EXISTING REPLACEMENT OLD MODEL/SERIAL # _______________________
COMMENTS: ____________________________________________________________________________________________________
AIR INLET __________PSID
CHECK VALVE______PSID
HELD at _____________PSID
CHECK VALVE
LEAKED
CLEANED
REPLACED
PVB / SVB
OPENED at ___________PSID
AIR INLET VALVE
DID NOT OPEN
DID IT FULLY OPEN
(YES NO )
MODEL:___________________
S/N:______________________
MAKE:___________________
DIFFERENTIAL PRESSURE GAUGE USED POTABLE NON-POTABLE
ASSEMBLY INSTALLED IN WHAT POSITION ? SERVICE RESTORED ? YES NO OTHER VERTICAL VERTICAL DOWN HORIZONTAL
TEST RESULTS
PASS FAIL
TEST RESULTS
THE ABOVE IS CERTIFIED TO BE TRUE AT THE TIME OF TESTING. *TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS [ 30 TAC §290.46 (B) ]
**USE ONLY MANUFACTURE’S REPLACEMENT PARTS
2ND CHECK ***
HELD TIGHT at ______PSID
LEAKED
CLOSED TIGHT
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________
CLEANED
REPLACED
CLOSED TIGHT _______PSID
NO
IS THE ASSEMBLY INSTALLED ON A NON-POTABLE WATER SUPPLY (AUXILIARY) ?
***2ND CHECK: NUMERIC READING REQUIRED FOR DCVA ONLY
YES
YES
NO
DATE: ___________ TIME: __________ AM/PM PHONE NUMBER: ________________________________
BPAT LICENSE # ____________________ LICENSED TESTER (PRINT):__________________________________
LICENSED TESTER (SIGNATURE): _______________________________LICENSE EX. DATE ________________
DATE: ___________ TIME: __________ AM/PM PHONE NUMBER: ________________________________
BPAT LICENSE # ____________________ LICENSED TESTER (PRINT):___________________________________
LICENSED TESTER (SIGNATURE): _______________________________LICENSE EX. DATE _________________
NEW
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