BPP-06-20-1259L -1 M
MIAMI-DADE WATER & SEWER DEPARTMENT
METER OPERTATIONS & MAINTENANCE
MIAMI•DADE
d CROSS -CONNECTION CONTROL UNIT
1001 N.W.11th STREET, MIAMI, FL 33136-2209
Phone (305) 547-M ? Fax (305) 545-9555
BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM
ADDRESS OF DEVICE:
`• 3o I, 'i>-�«c
OWNER OF DEVICE: !�
Maur
OWNER CONTACT:
-C_n .-. ev-
PHONE:: FAX:
ADDRESS OF OWNER:
1 3� C q �: S �CC[
ZIP CODE::
\ C^Y�'�! SI.�r r �� . _3 3 \ 3 �
NAME OF TESTER: , CERTI ICATION #: EXPIRATION DATE:: PHONE
2 .� 0E V C.,�� r�fi' 17. i 0_: 02 - 03402�� .3 3LI � 1Ez'
BUSINESS NA BUSlNE ADDRESS: ~' ZIP CODE;
.;A - i-w�.1 r i -i r�rM�)a„� i'N� iUC � 5�.: ,2-I S( 'ui LC� n,'-1 r- -� j►�7�
3 ST KIT MODEL #:
� c� `lo. �-A
SERIAL #: DATE LAST CAL. SITE TUBE:
YES 1 NO
R.P. D.C. P.V.B.
MAKE OF ASSEMBLY: MODEL NO:
SERIAL #: SIZE.
;11� , 2- l
Go �q 5 C 2
LOCAT!ONOFA MBLY-
C :�1 i e j C �+�4�
HAZARDISERVICE�lzC.✓ INO,
Lc5 I n l� ✓ METER1( vol
4
INITIAL TEST: ANNUAL TEST:
DATE OF TEST: O O METER READING:
V t
SHUT OFF VALVE #1: SHUT OFF VALVE #2
CLOSED TIGHT: CLOSED TIGHT:. ._
TLINESSURE: PRESSURE STABLE:
LEAKED: LEAKED:
E5 NO
f
D.C.V.A.
R.P.Z.A. P.V.B.
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:: _
I`-- Leaked: Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DIFFERENTIAL ACROSS CHECK
OPENED AT: HELD AT:
PSI PSI
OPENED AT: PSI. 3 .2 PSI ) PSI
IF THE ASSEMBLY FAILS FOR ANY REASON, COMPLETE THIS SECTION AND NOTE REPAIRS
REMARKS / REASON FOR FAILURE (IF APPARENT):
CHECK VAVLE NO.1 CHECK VAVLE NO.2
DIFFERENTIAL RELIEF VALVE P.V.B.
CLEANED: CLEANED:
�
CLEANED: CLEANED:
a REPLACED: REPLACED:
REPLACED: REPLACED:
W
D.C.V.A.
R.P.ZA. P.V.B.
CHECK VALVE NO. 1 CHECK VALVE NO.2
DIFFERENTIAL RELIEF VALVE AIR INLET CHECK VALVE
�- Closed Tight: Closed Tight:
W g g
FAILED TO OPEN:, LEAKED: _
FAILED TO OPEN:
~
OPENED AT: HELD AT:
Leaked: Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK PRESSURE DIFFERENTIAL ACROSS CHECK
OPENED AT: PSI PSI PSI
PSI PSI
(CERTIFY THAT I HAVE TESTED THE ABOVE ASSEMBLY IN ACCORDANCE WITH THE A.-W W.A_ CROSS CONNECTION CONTROL MANUAL AND THAT ALL THE INFORMATION IS
ACCURATE TO THE BEST OF MY ABILITIES.
SIGNATURE OF CERTIFIED TESTER
DATE:
0oJ�2�
FOR OFFICE USE ONLY:
DATE:
Revised: 01 /10/2005 www.miamidade.gov/wasd/backfiow.asp