BACKFLOW PREVENTION ASSEMBLY TEST AND …
San Antonio Water System #00150018 2800 US Hwy 281 N San Antonio, TX 78212-3106 Attention: BACKFLOW PREVENTION Section ASSEMBLY Location / Unit being Protected_______________________________ ______________________________________ SUBJECT: Test and Maintenance Report BACKFLOW PREVENTION ASSEMBLY (Circle one) RP DC PVB SPVB RPDA DCDA Please be advised that we have made the following periodic test as required by TCEQ and the San Antonio Water System s Cross Connection Control Program and report the following: Manufacturer and Model of Assembly____________________________ ASSEMBLY Serial ______________________Size______ Service Address_______________________________ BKFL#___________Gauge #____________Gauge Exp Date_______ CHECK #1 CHECK #2 DIFF.
The following form must be completed for each assembly tested. A signed and dated original must be submitted to the public water supplier for recordkeeping purposes*
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