Backflow Test Permit And Maintenance Report Template - City Of Rosenberg Code Enforcement Department

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CITY OF ROSENBERG PERMIT
Code Enforcement Department
P.O. Box 32 * 2220 Fourth Street * Rosenberg, TX 77471
Phone: (832)595-3500 Fax: (832)595-3501 * Inspection Request Line (832)595-3401
BACKFLOW TEST AND MAINTENANCE REPORT
**The ORIGINAL COPY of this form MUST be submitted to the City Hall Annex – NO FAXED OR EMAILED FORMS WILL BE
ACCEPTED – NO EXCEPTIONS!!!
Service Address:
Customer Name:
Manufacturer:
Model:
S/N :
Size:
Location of Device:
PWS I.D. #:
790003
Contact Person:
Contact No.
Mailing Address (if different from service address): ________
________________________________________________
TYPE OF ASSEMBLY
Reduced Pressure Principle (RP)
Vacuum Breaker (VB)
Pressure Vacuum Breaker (PVB)
Double Check Detector Assembly (DCD)
Atmospheric Vacuum Breaker (AVB)
Double Check Valve (DCV)
Spill Resistant Pressure Vacuum Breaker (SVB)
Is this assembly installed in accordance with City of Rosenberg Ordinance 2008-47?
Yes
No
REDUCED PRESSURE PRINCIPLE ASSEMBLY
PRESSURE VACUUM BREAKER & SVB
DOUBLE CHECK ASSEMBLY VALVE
RELIEF VALVE
AIR INLET
CHECK VALVE
CHECK VALVE #1
CHECK VALVE #2
D.C. CLOSED TIGHT
CLOSED TIGHT
OPENED AT
OPENED AT:
HELD AT:
INITIAL TEST
RP_________PSID
__________ PSID
__________PSID
__________PSID
_________PSID
__________
LEAKED
LEAKED
DID NOT OPEN
DID NOT OPEN
LEAKED
REPAIRS** AND
MATERIALS USED
HELD AT
FINAL TEST
D.C. CLOSED TIGHT
CLOSED TIGHT
OPENED AT
OPENED AT
__________ PSID
~
_________
RP __________ PSID
__________ PSID
~
__________ PSID
__________ PSID
Test Gauge Used: Make/Model: _______________________
S/N: __________________
Calibration Date: __________
Comments: _______________________________________________________________________________________________________
Certifications: I hereby certify that the foregoing data is accurate and reflects the proper operation and maintenance of the caption equipment.
I personally performed or directly supervised 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 the City of Rosenberg Code Enforcement
Department.
________________
Company Name
Company Address
Company Phone
Tester Name
Signature Certified Tester
Date
PERMIT FEE: $10.00*
Type of System:
Domestic Waterline
Irrigation
Fire Line
New Installation
Permit Number Issued: _____________________
Rev. 012517-JL

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