Backflow Prevention Assembly Test Report & Maintenance Report Form
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1City of Bedford
Backflow Prevention Assembly Test Report
&
Public Services Water Department
Maintenance Report
1813 Reliance Parkway
Bedford, Texas 76021
PWS ID # 2200003
Phone: 817-952-2298
Installation Test (New)
Installation Test (Replacement)
Fax 817-952-2240
Annual Test (Existing Device)
___________________________________
Business Name:
Install Date:
______/______/______
__________________________________
Physical Address:
___________________________________
Mailing Address:
Installed by: ____________________________
_______________________________________________
:___________________________________
Property Owner
Test Date:
______/______/______
:_______________________________
Location of Assembly
Manufacturer: ___________________________
_______________________________________________
Model #:___________________
Is this assembly installed in accordance with manufacturer
recommendation and/or local codes?________
Serial #:____________________
Replaces Serial #:_______________________
Size:_____________ Line PSI:__________
Reduced Pressure Principle Assembly
TYPE OF ASSEMBLY
RP
DC
RPDA
Double Check Valve Assembly
PVB
DCDA
OTHER
SVB
PVB / SVB
Check Valve #1
Check Valve #2
Relief Valve
AIR INLET
Closed Tight
Closed Tight
Did Not Open
Initial
Leaked
Leaked
Opened
Did Not Open
Test
Opened
Held at ________ PSID
Held at ________ PSID
Opened at _______ PSID
Opened at ________ PSID
Held Backpressure
Pass
Fail
# 2 Shutoff Valve
Pass
Fail
CHECK VALVE
Cleaned
Cleaned
Cleaned
Leaked
Repairs
Replaced
Replaced
Replaced
Held at __________ PSID
Cleaned
Replaced
Closed Tight
Closed Tight
Opened
AIR INLET
Final
Opened at ________ PSID
Test
Held at ________ PSID
Held at ________ PSID
Opened at _______ PSID
CHECK VALVE
Held at
________ PSID
Held Backpressure
Pass
Fail
# 2 Shutoff Valve
Pass
Fail
The following prevention assembly detailed has been tested and maintained as required by TCEQ regulations and is
certified to be operating within acceptable parameters.
The above report is certified to be correct.
Test Gauge Used Make/Model
SN:
Calibration Date
Firm Name
Phone
Firm Address
Date
Certified Tester
Name
Signature
Bedford Registration Number
The original portion of this form must be signed, dated and returned to the City of Bedford Backflow Prevention
Division.
*TEST RECORDS MUST BE KEPT FOR AT LEAST THREE YEARS**USE ONLY MANUFACTURER’S REPLACEMENT PARTS
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