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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 M c Kinney 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 M c KINNEY, 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): M c KINNEY, 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
