Attachment 5-- Backflow Device Test Form - NA -- 1pgs..pdf
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- Attached to
- RPR Chiller Building 10504 Federal contract opportunity
- Solicitation number
- FA301620B0018
About this file
This document includes a backflow prevention assembly test form and details of a federal contract opportunity for an HVAC project. The test form is for a double check detector assembly and includes inspection details for various components as well as certification signatures.
The federal contract opportunity is for the demolition and replacement of an existing air-cooled chiller at Building 10504. The project value is between $500,000 and $1,000,000 and Davis-Bacon wage rates apply. The solicitation is set aside for women-owned small businesses. Offerors must complete various SF-1442 forms and include a cost proposal in RS Means format with any supporting documents. The deadline for electronic bid submission is through the points of contact listed in Section L. The contracting agency is the Air Force Air Education and Training Command.
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Text version
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. 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: 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:
Lower ( ) Other, Describe ( )
FINAL P.S.I. 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.
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. 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
(Check One) Residential____ Commercial ______
(Check One) Domestic ____ Irrigation ______
(Check One) Containment____ Internal ________
File details come from the government source that posted it. Updated .