Reduced Pressure Principle Reduced Pressure Principle-Detector
Double Check Valve Double Check-Detector
Pressure Vacuum Breaker Spill-Resistant Pressure Vacuum Breaker
City of Glenn Heights
2118 S Uhl Rd, Glenn Heights, TX 75154
(972) 274-5100
Backflow Prevention Assembly Test and Maintenance Report
All information MUST be filled out or test is invalid
(ONLY Originals Excepted)
PHONE:_____________________________________
FAX:________________________________________
NAME OF PWS:_____________________________________
PWS ID #:__________________________________________
NAME:____________________________________________
CONTACT:_________________________________________
LOCATION:________________________________________
MAILING ADDRESS:_________________________________
TYPE OF ASSEMBLY
Size ____________________________________
Serial Number ____________________________
Manufacturer ________________________________
Model Number _______________________________
Located At __________________________________
Is the assembly installed in accordance with manufacturer recommendations and/or local codes? ______
Reduced Pressure Principle Assembly
Pressure Vacuum Breaker
Double Check Valve Assembly
1st Check 2nd Check
Relief Valve Air Inlet Check Valve
Held at ___
psid
Held at ___
psid
Opened at ___
psid
Opened at ___
psid
Held at ___
psid
Initial Test
Closed Tight Closed Tight Did not open Did not open Leaked
Leaked Leaked
Repairs
and
Materials
Used
Held at ___
psid
Held at ___
psid
Test After
Repair
Closed Tight Closed Tight
Opened at ___
psid
Opened at ___
psid
Held at ___
psid
Test gauge used: Make/Model_________________ SN:_____________ Calibration Date:____________
Remarks:____________________________________________________________
The above is certified to be true at the time of testing.
Firm Name ________________________ Certified Tester (print)___________________
Firm Address _______________________ Certified Tester (signature)________________
Firm Phone #_______________________ Cert. Tester No.___________ Test Date___________
* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS
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.
City of Glenn Heights
0570085
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