Fillable CITY OF STEPHENVILLE BACKFLOW PREVENTION ASSEMBLY TEST AND (City of Stephenville)

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CITY OF STEPHENVILLE BACKFLOW PREVENTION ASSEMBLY TEST AND (City of Stephenville)

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  • 42 other fields

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File type: PDF

U.S.A. forms for City of Stephenville

BROWSE CITY OF STEPHENVILLE (TX) FORMS

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298 W. Washington – Stephenville, TX 76401 Online Form: Phone: (254) 918-1213/918-1214
Backflow Report www.ci.stephenville.tx.us/Ordinance%20&%20Code/Forms/forms.html Fax: (254) 918- 1207
Permit # _____________New Irrigation______
Incode Chart Map
(City use Only)
(Please Circle)
Pass / Fail
CITY OF STEPHENVILLE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
The following form must be completed for each assembly tested. A signed and dated original must be submitted
to the Building Inspector’s Office within 5 days of the test for record keeping purposes.
NAME OF PWS: STEPHENVILLE
PWS I.D. # 0720002
Establishment: __________________________________________
ADDRESS: ____________________________________________
Owner’s Name__________________________________________
Mailing Address_____________________________________________Contact:__________________________
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ. Regulations and is certified
to be operating within acceptable parameters.
Rain & Freeze tested_______ TYPE OF ASSEMBLY
( ) Reduced Pressure Principle ( ) RPP Detector
( ) Double Check Valve ( ) DC-Detector
( ) Pressure Vacuum Breaker ( ) AVB ________________________Street name
r ( ) Spill-Resistant Pressure Vacuum Breaker ( ) OTHER LOCATION DRAWING HERE
Manufacturer: _____________________ Size: ____________ Model Number: ______________________________
Located At: __________________________________________ Serial Number:_______________________________
____________________________________________________ Description:__________________________________
(General Description) – Ex.:(Service Line, Lawn Irrigation, Fire, Soda, Boiler, etc.)
Is the assembly installed in accordance with manufacturer recommendations and/or local codes?
Test Gauge
Used
Make/Model
CONBRACO 40-200-TK
Serial #
3032283
Calibration Expiration Date:
REPLACEMENT
Firm Name
Firm Physical Address & City, State Zip:
Firm Phone #
E-mail Address
Certified Tester (Print Name):
I certify this document to be true at the time of testing
____________________________ _________
Signature Date
Certified #: Expiration Date:
REMARKS:____________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS (USE ONLY MANUFACTURER’S REPLACEMENT PARTS)
Initial Test
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Test point #1
Double Check Valve Assembly
Air Inlet
Check Valve
1st Check
2nd Check
Relief Valve
Initial Static held
at _____p.s.i.
Held at psid
Closed Tight
Leaked
Held at psid
Closed Tight
Leaked
Opened at psid
Did not open
Opened at psid
Did not open
Held at____psid
Leaked
Repairs and
Materials Used
Test After
Repair
Held at____psid
Closed Tight
Held at_____psid
Closed Tight
Opened at psid
Opened at psid
Held at____psid
Notify Property
Owner
YES NO
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signature
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298 W. Washington – Stephenville, TX 76401 Online Form: Phone: (254) 918-1213/918-1214
Backflow Report www.ci.stephenville.tx.us/Ordinance%20&%20Code/Forms/forms.html Fax: (254) 918- 1207
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CITY OF STEPHENVILLE BACKFLOW PREVENTION ASSEMBLY TEST AND (City of Stephenville)

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Completed 24 January 2021

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