CITY OF KIRBY
112 BAUMAN
KIRBY, TX 78219

Attention: Public Works Department

SUBJECT: Test and Maintenance Report - Backflow Prevention Device

Please be advised that we have made the fallowing periodic test as required by the City of Kirby Cross Connection Control Program and report the following:

Name mid Model of Device_____________ Device Serial #____________________Size________

Service Address____________________________________________Gauge#_______________

NOTE: Circle appropriate item

	CHECK #1 VALVE	CHECK #2 VALVE	DIFF. PRESSURE RELIEF VALVE	PRESSURE VACUUM BREAKER
INITIAL TEST	1. Leaked 2. Closed Tight	1. Leaked 2. Closed Tight	Opened at _____lbs.     Reduced Pressure Did Not Open	Air Inlet     Opened at ______PSID Did Not Open
REPAIRS	Cleaned Replaced    Disc    Spring    Guide    Pin Retainer    Hinge Pin'    Seat    Diaphragm    Other, describe	Cleaned Replaced    Disc    Spring    Guide    Pin Retainer    Hinge Pin'    Seat    Diaphragm    Other, describe	Cleaned Replaced:      Disc:          Upper          Lower      Spring:      Diaphragm:          Large:             Upper             Lower         Small      Seat:         Upper         Lower      Spacer:         Lower         Other,describe	Check Valve      Held at ______PSID         Leaked
				Cleaned Replaced:      Air Inlet Disc      Check Disc      Air Inlet Spring      Check Spring      Other, describe
FINAL TEST	P.S.I Drop (R/P)____ Closed Tight	Closed Tight	Opened at _____lbs.    Reduced Pressure	Air Inlet ___________PSID Check Valve ________PSID

CERTIFICATIONS:

1. I hereby certify that the foregoing data is accurate and reflects the proper operation and rnaintenance of the captioned equipment. I personally performed or directly supervised the field test herein described. I hereby certify that the Test Guage listed above, has been Certified within the last twelve (12) months and a copy of the certification has been submitted to the City of Kirby Public Works Dept.

_________________    ______________________________    __________________________
DATE                            SIGNATURE CERTIFIED TESTER       PLUMBING COMPANY

2. I hereby certify the device has been inconstant use at this location in a manner approved by the City of Kirby during the entire prescribed interval between test periods and during this period this device was not by-passed, made inoperative or removed without proper authorization. Al1 defects found during the operating period or during tests of the device were immediately corrected tothe specification and approval of the City of Kirby.

_____________________________    _______________________________________________
FIRM NAME                                        ADDRESS

___________________     __________________________________     ____________________
TELEPHONE NO.             TITLE                                                               DATE

________________________________________
SIGNATURE OWNER OR REPRESENTATIVE