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.
