TECHNICAL_EXHIBIT_AE_BACKFLOW_ASSEMBLY_TEST_CHECKLIST.docx
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- Fire Protection Services, Fort Hood, TX
- Solicitation number
- W91151-16-R-0013
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TECHNICAL EXHIBIT AE BACKFLOW ASSEMBLY TEST CHECKLIST
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TECHNICAL EXHIBIT AE
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE CHECKLIST
The following form must be completed for each assembly tested. A signed and dated original must be submitted to the Contracting Officer Representative:
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Mailing Address: 4612 Engineer Drive Fort Hood, TX 76544 Contact Person: Contracting Officer Representative Location of Service: ________________________
The backflow prevention assembly detailed below has been tested and maintained as required by TCEQ regulations and is certified to be operating within acceptable parameters.
TYPE OF ASSEMBLY
| Manufacturer | ___________________ | Size ____________________ | |
| Model Number __________________ | Location _________________ | ||
| Serial Number __________________ | Service _________________ |
Reduced Pressure Principle Assembly
| Inlet Line Pressure PSI |
| Check Valve #1 |
Check Valve #2
Closed Tight
Closed Tight
Leaked
Leaked
PSI
PSI
| Apparent Reading |
| Pressure Differential Relief Valve |
Opened at _____________________ PSI.
| Approved: |
| Did Not Open ____________ |
Disapproved:
Test gauge used: Make/Model___________________________________________________
SN: _________________________________________________________________________
Calibration Date: ______________________________________________________________
The above is certified to be true at the time of testing.
| Firm Name _____________________ | Certified Tester___________________ |
| Firm Address____________________ | Cert. Tester Number: _______________ |
| Firm Phone # ___________________ | Date: ___________________________ |
TEST RECORDS SHALL BE KEPT FOR AT LEAST THREE YEARS
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