Fillable BUILDINGBACKFLOW PREVENTION ASSEMBLY CERTIFIED TEST REPORT (City of West University Place)

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BUILDINGBACKFLOW PREVENTION ASSEMBLY CERTIFIED TEST REPORT (City of West University Place)

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3826 AMHERST ST. WEST UNIVERSITY PLACE, TX 77005 | 713.662.5833 | INSPECTIONS@WESTUTX.GOV
PAGE 1 OF 1
Public Works Department
Development Services
INSPECTION REQUEST LINE 713.662.5805 | BEFORE 4:30 Pm FOR NEXT DAY
BUILDING–BACKFLOW PREVENTION
ASSEMBLY CERTIFIED TEST REPORT
BACKFLOW PREVENTION ASSEMBLY CERTIFIED TEST REPORT
PROPERTY
PROJECT NAME
PROPERTY ADDRESS
MAILING ADDRESS
CONTACT FIRST NAME LAST NAME
PHONE NUMBER EMAIL
ASSEMBLY TYPE
REDUCED PRESSURE PRINCIPLE (RP) REDUCED PRESSURE PRINCIPLE-DETECTOR (RPD)
PRESSURE VACUUM BREAKER (PBV) DOUBLE CHECK VALUE (DCV) SPILL RESISTANT PRESSURE VACUUM BREAKER (SVB)
THE BACKUP PREVENTION ASSEMBLY DETAILED HEREON HAS BEEN TESTED AN MAINTAINED AS REQUIRED BY TCEQ-CHAPTER 290,
RULES AND REGULATIONS FOR PUBLIC WATER SYSTEMS, CITY'S UNIFORM PLUMBING CODE, AND IS CERTIFIED TO COMPLY WITH THE
REQUIREMENTS.
DATE INSTALLED
MANUFACTURER MODEL NUMBER SERIAL NUMBER SIZE LOCATED AT
IS THE ASSEMBLY INSTALLED IN ACCORDANCE WITH MANUFACTURER RECOMMENDATION AND/OR CITY'S UNIFORM PLUMING CODE?
YES NO
REDUCED PRESSURE PRINCIPLE ASSEMBLY PRESSURE VACUUM BREAKER & SVB
DOUBLE CHECK VALVE ASSEMBLY RELIEF VALVE AIR INLET CHECK VALVE
CHECK VALVE #1 CHECK VALVE #2
INITIAL TEST
D.C. CLOSED TIGHT
RP ____________ PSI
LEAKED
CLOSED TIGHT
____________ PSI
LEAKED
OPENED AT
____________ PSI
LEAKED
OPENED AT
____________ PSI
LEAKED
HELD AT
____________ PSI
LEAKED
**REPAIRS AND
MATERIAL USED
FINAL TEST
D.C. CLOSED TIGHT
RP ____________ PSI
CLOSED TIGHT
____________ PSI
OPENED AT
____________ PSI
OPENED AT
____________ PSI
HELD AT
____________ PSI
NOTES
* TEST REPORTS MUST BE KEPT FOR AT LEAST THREE YEARS.
TESTING IS REQUIRED UPON INSTALLATION, REPAIR, OR RELOCATION AND ANNUALLY THEREAFTER.
** USE ONLY MANUFACTURE REPLACEMENT PARTS.
TESTING CONTRACTOR
COMPANY NAME
CONTRACTOR REGISTRATION
NUMBER.
COMPANY ADDRESS
PHONE NUMBER
CERTIFIED TESTER
FIRST NAME LAST NAME
CERTIFIED TESTER NUMBER
W. O. C. ENGINEER
TEST DATE
ACKNOWLEDGMENT
THE ABOVE TEST IS CERTIFIED TO BE TRUE AT THE TIME OF
TESTING.
BACKFLOW TEST STATUS
PASS FAIL
SIGNATURE OF CERTIFIED TESTER DATE
PRINT NAME
TEST GAUGE USED
MAKE/MODEL SERIAL NUMBER
CALIBRATION DATE (Tested Annually)
REMARKS
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BUILDINGBACKFLOW PREVENTION ASSEMBLY CERTIFIED TEST REPORT (City of West University Place)

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Completed 17 July 2020

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