CC-18-2250CC ►a-2uo
Pereblys Service and Repairs Inc. PLC-11�IQ_-�/[34
V��l3335 w 13th Ave11 O
Hialeah, F133012
305-528-3115
BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM
ADDRESS OF DEVICE: f
,175 NE 96 St Miami FL33150
OWNER OF DEVICE:
Westland Plumbing Inc
OWNER CONTACT:
PHONE::
FAX:
1
ADDRESS OF OWNER
ZIP CODE::
NAME OF TESTER:
CERTIFICATION #:
EXPIRATION DATE::
PHONE::
Ebl s Pereda
16230
04/17/19
305-528-3115
2
BUSINESS NAME:
BUSINESS ADDRESS:
LP CODE:
Pereblys Services And Repair INC
3335 W 13 Ave Hialeah FI
33012
3
TEST KIT MAKE::
MODEL#:
SERIAL#:
DATE LAST CAL.
SITE TUBE:
Backflow artde o t
MTK-15
03161399
07/13/2018
YES I NO
f"TEST _
t.'
MAKE OF ASSEMBLY:
MODEL NO:
SERIAL#:
SIZE:
314"
Apollo
RPLF4A
922475
LOCATION OF ASSEMBLY:
Back north side of the building
HA2ARD/SERVICE:
Domestic
METER NO.
4
INITIAL TEST: x ANNUAL TEST:
DATE OF TEST-12-10-2018
METER READING:
SHUT OFF VALVE IM: X
SHUT OFF VALVE #2: X
CLOSED TIGHT:
CLOSED TIGHT:
LINE PRESSURE: 50 PSI
PRESSURE STABLE: YES - NO
LEAKED:
LEAKED:
...W , 5K. s -� . ' -�D C.V:A (`z r,e7`,
CHECK VALVE NO.1
CHECK VALVE NO.2
DIFFERENTIAL RELIEF VALVE
AIR INLET
CHECK VALVE
XFAILED
TO OPEN:_
LEAKED:_
N
Closed Tight:
Closed Tight:
FAILED TO OPEN:
IV-j
Leaked:
Leaked:
OPENED AT:
PRESSURE DIFFERENTIAL ACROSS CHECK
PRESSURE DIFFERENTIAL ACROSS CHECK
3.3
HELD AT:
8.9
2.1
OPENED AT: PSI•
PSI
PSI
PSI
PSI
1F�T4JE►�SSEMB_tY,A1LS.F�OR At'RpSQN;GOMPJ.ITE
REMARKS / REASON FOR FAILURE (IF APPARENT):
4 � � � CHECK VAVLE N0 +f °
a •. � �tCH�CK VAVLE�NO 2 �^ ``�� §
rt'i� >i DIFFEREA[TIAL RELIEF VALVE. 4 >
r `' A P`Y4B. j
N
CLEANED:
CLEANED:
CLEANED:
CLEANED:
Q
REPLACED:
REPLACED:
REPLACED:
REPLACED:
d
W
Ix..
nJ�A � 1s`•' ., *D:G V A ,x ,- �;b� • '� t° +�R:PZ:k. •14"-�
,,.. , .� _
CHECK VALVE NO.1
CHECK VALVE NO.2
DIFFERENTIAL RELIEF VALVE
AIR INLET
CHECK VALVE
N
Closed Tight:
Closed Tight:
FAILED TO OPEN:
FAILED TO OPEN:_
LEAKED:_
H
OPENED AT:
HELD AT:
LLJ
OC
Leaked:
Leaked:
PSI
PSI
PRESSURE DIFFERENTIAL ACROSS CHECK
PRESSURE DIFFERENTIAL ACROSS CHECK
OPENED AT: PSI
PSI
PSI
I CERTIFY
{ATl i fAVE,TESTED;THE-ABOVE ASSEMBL`-Y 1N ACCORDANCE WITH THE A.W WA,
CROSS CONNECTION CONTROL MANUAI AND CHAT ALL THE;INFORMATION IS-.
Ate. ,.
.:A Woffe-0.
•.e ... - � f.yn:l+ r ate.. r.:.Y •'*'�
iE I :O IY L�I�ES.,,
_
' _ .rn- .tf " -` `. s"•i'4. t ..s r a
SIGNATURE OF CERTIFIED TESTER:
— —
DATE:
12-10-2018
NOTE: TEST FORM MUST BE COMPLETED IN ITS ENTIRETY. INCOMPLETE TEST FORMS WILL. BE RETURNEE).
Revised: 5/27/2010 e-mail: CCC@miamidade.gov web: http:/twww.miamidade.govtwater/cross-connection-backfiow.asp