402
1100 Red Bluff Rd. Seabrook, TX 77586 Phone: 281-291-5669 Fax: 281-291-2364
Owner:
Street:
City, State, Zip:
Phone:
E-Mail:
Type of Assembly:
Reduced Pressure Principal
□
Reduced Pressure Principal - Detector
□
Check Type that Applies
Double Check Valve
□
Double Check Valve
□
Pressure Vacuum Breaker
□
Spill - Resistant Pressure Vacuum Breaker
□
Manufacturer: Model#: Size: Serial#:
Location: DateInstalled:
Yes
□
No
□
Initial Test
PSI PSI PSI PSI PSI
Closed Tight
□
Closed Tight
□
Did not Open
□
Did not Open
□
Leaked
□
Leaked
□
Leaked
□
PSI PSI PSI PSI PSI
Closed Tight
□
Closed Tight
□
The Above is certified to be true By:
Firm Name:
CertifiedTester:
Street:
TesterNo:
City, State, Zip:
Phone:
Date:
E-Mail:
Approved
By: Date:
BUILDINGDEPARTMENT Revised:March1,2019
Reduced Pressure Principal Assembly
Double Check Valve Assembly
Air Inlet Check Valve
Pressure Vacuum Breaker
Relief Valve2nd Check1st Check
Backflow Assembly Certified Test Report
City of Seabrook
Test After
Repairs
Opened atHeld AtHeld At
Held At Held At Opened at
ThisAssemblyisinstalledinaccordancewithmanufacturersRecommendationsand
/orlocalcodes?
Repairs and
Materials
Used
Held AtOpened at
Opened at Opened at
