Backflow Prevention Assembly Test And Maintenance Report
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2Figure: 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
Relief Valve
Air Inlet
Check Valve
1st Check
2nd Check
Held at ___
Held at ___
Opened at ___
Opened at ___
Held at ___
psid
psid
psid
psid
psid
Initial Test
Closed Tight
Closed Tight
Did not open
Did not open
Leaked
Leaked
Leaked
Repairs
and
Materials
Used
Held at ___
Held at ___
Test After
Opened at ___
Opened at ___
Held at ___
psid
psid
Repair
psid
psid
psid
Closed Tight
Closed Tight
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