Frisco - Backflow Solutions, Inc.

Property Name

Property Name*

Mailing Name*

Backflow Assembly

The backflow prevention assembly detailed below has been tested and maintained by Texas Commission on Environmental Quality (TCEQ) regulations and is to be operating within acceptable parameters.

Location of Device*

Please put detailed description of the location. (For example, NE corner of the mechanical room or garage south wall)

Manufacturer*

Other Manufacturer*

Model Number*

Size*

Serial Number*

Permit Number Prefix*

Permit Number*

Current Device Being Replaced*

Meter Number*

What is the Domestic Servicing?*

Test Information

Test Date*

Check Valve #1

Initial Test Value*

Check Valve #2

Initial Test Value*

Relief Valve

Initial Test Value*

Air Let

Check Valve

Remarks

Retest After Repair

Test Date

Remarks

Tester Information

License Number*

Testing License Expiration*

Test Gauge Make*

Test Gauge Model*

Test Gauge Serial Number*

Test Gauge Date Last Tested For Accuracy*

Testing Company*

Contact Phone

Contact Email

Address

Signed By*

City of Frisco

Backflow Assembly

Test Information

Check Valve #1

Check Valve #2

Relief Valve

Air Let

Check Valve

Retest After Repair

Tester Information

Company

Services

Education