Texas Commission on Environmental Quality

Figure: 30 TAC §290.47(f)

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:

BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT

NAME OF PWS: ______________________________________________________________
PWS I.D.: #___________________________________________________________________
MAILING ADDRESS: __________________________________________________________
CONTACT PERSON: __________________________________________________________
LOCATION OF SERVICE: ______________________________________________________

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.

TYPE OF ASSEMBLY

           ¨ Reduced Pressure Principle                                 ¨ Reduced Pressure Principle-Detector
           ¨ Double Check Valve                                           ¨ Double Check-Detector
           ¨ Pressure Vacuum Breaker                                   ¨ Spill-Resistant Pressure Vacuum Breaker

Manufacturer____________________ Size _________________________________
Model Number__________________ Located At ___________________________
Serial Number_____________________________________________________________

Is the assembly installed in accordance with manufacturer recommendations and/or local codes?______

	Reduced Pressure Principle Assembly			Pressure Vacuum Breaker
	Double Check Valve Assembly			Air Inlet	Check Valve
	1st Check	2nd Check	Relief Valve	Air Inlet	Check Valve
Initial Test	Held at ____ psid Closed Tight ¨ Leaked ¨	Held at ____ psid Closed Tight ¨ Leaked ¨	Opened at ___ psid Did not open ¨	Opened at ____ psid Did not open ¨	Held at _____ psid Leaked ¨
Repairs and Materials Used
Test After Repair	Held at ____ psid Closed Tight ¨	Held at ____ psid 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 ______________________
Firm Address ______________________ Cert. Tester No. __________ Date_______
Firm Phone #______________________

* TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS
** USE ONLY MANUFACTURER'S REPLACEMENT PARTS