BACKFLOW PREVENTION ASSEMBLY TEST AND …

1 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.

2 PRESSURE PRESSURE VACUUM VALVE VALVE RELIEF VALVE BREAKER INI- 1. Leaked ( ) 1. Leaked ( ) Opened at_____ PSID Air Inlet TIAL Did Not Open ( ) Opened at_____ PSID TEST 2. Closed Tight ( ) 2. Closed Tight ( ) Leaking ( ) Did Not Open ( ) Cleaned ( ) Cleaned ( ) Cleaned ( ) Check Valve Replaced: Replaced: Replaced: Held at _____PSI Disc ( ) Disc ( ) Disc.

3 Leaked ( ) Spring ( ) Spring ( ) Upper ( ) R Guide ( ) Guide ( ) Lower ( ) Cleaned ( ) E Pin Retainer ( ) Pin Retainer ( ) Spring ( ) Replaced: P Hinge Pin ( ) Hinge Pin ( ) Diaphragm: Air Inlet Disc ( ) A Seat ( ) Seat ( ) Large: Check Disc ( ) I Diaphragm ( ) Diaphragm ( ) Upper ( ) Air Inlet Spring ( ) R Other, Describe ( ) Other, Describe ( ) Lower ( ) Check Spring ( ) S Small ( ) Other, Describe ( ) Seat: Upper ( ) Lower ( ) Spacer.

4 Lower ( ) Other, Describe ( ) FINAL Drop (R/P) _____ Air Inlet _____PSID TEST Closed Tight ( ) Closed Tight ( ) Opened at_____ PSID Check Valve_____ PSID CERTIFICATIONS: 1. I hereby certify that the foregoing data is accurate and reflects the proper operation and maintenance of the captioned equipment. I personally performed the field test herein described. I hereby certify that the Test Gauge listed above has been certified within the last twelve (12) months and a copy of the certification has been submitted to SAWS.

5 The ASSEMBLY is installed in accordance with manufacturer recommendations and/or local codes. Yes____ NO____ Test Date _____ Time _____ am ( ) pm ( ) BPAT Tester Number _____Exp Date_____ _____ _____ _____ _____ (____)_____ SIGNATURE CERTIFIED TESTING COMPANY NAME ADDRESS/CITY ZIP PHONE _____ Print Name 2. I hereby certify the ASSEMBLY has been in constant use at this location in a manner approved by the San Antonio Water System during the entire prescribed interval between test periods and during this period this ASSEMBLY was not by-passed, made inoperative or removed without proper authorization.

6 All defects found during the operating period or during tests of the ASSEMBLY were immediately corrected to the specification and approval of the San Antonio Water System. _____ _____ FIRM NAME ADDRESS CITY ZIP _____ _____ _____ TELEPHONE NUMBER TITLE DATE _____ _____ SIGNATURE OWNER OR REPRESENTATIVE PRINTED NAME OWNER OR REPRESENTATIVE

7 (Check One) Residential____ Commercial _____ (Check One) Domestic ____ Irrigation _____ (Check One) Containment____ Internal _____