RC-18-3757 (3)MIAMI-DADE WATER & SEWER DEPARTMENT
METER OPERTATIONS $ MAINTENANCE
MIAMI•DIADE C—� Z l� CROSS -CONNECTION CONTROL UNIT
31 1001 N.W.11t+ STREET, MIAMI, FL 33136.2209
Phone (305) 547-3046 Fax(786)268.5485
BACKFLOW PREVENTION ASSE LY TEST REPORT FORM
ADDRUS OF DEVICE: 1 n_ ,
Od
OWNER OF DEVICE: O
J' /�XA
ER COtJTACT.PHONE::
FAX'
1
W
3 a O /3
ADDRESS OF OWNER: n A
V
ZIP Cam"
NAME OF TESTER:
CERTIFICATION #:�
EXPIRA'n E, a
PHONE:t
2
BU INESS NA E: . } n
BU IADDRESS: �y
ZIP CODE:
333/
-
W Jt�l
b. , a/(
3
TEST KIT E:: p
�l ®
ODEL #:
SE #: [j
DATE T
a
SITE TU
0
J /
YES / 0
TEST PLEASE MARK: R.P. D.C.P.V.B.
MAKE OF ASSEMBLY:
MODEL NO:
SERIAL #:
f
SIZE:oft
AOL
LOCATION OF ASSEMBLY' �
HAZARD_i RV�����
METER N0.
4
INITIAL TEST: ANNUAL TEST:
DATE OF TEST: !
METER READING ID a , 0
SHUT OFF VALVE 11:
SHUT OFF VALVE 02: 1
��. ���
`� J�
CLOSED TIGHT:
CLOSED TIGHT:
LINE PRESSURE: /
PRESSURE STABL :YES NO
LEAKED:
LEAKED:
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
Closed Tight:
Closed Tight:
FAILED TO OPEN:
FAILED TO OPEN:_
LEAKED:_
H
Leaked
Leaked:
OPENED AT:
HELD AT:
PRESSURE DIFFERENTIAL ACROSS CHECK
PRESSURE DIFFERENTIAL ACROSS CHECK
OPENED AT: PSI•
o/ V
gPSI
PSI
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.
CO)
CLEANED:
CLEANED:
CLEANED:
CLEANED:
Ix
Q
REPLACED:
REPLACED:
REPLACED:
REPLACED:
a
W
D.C.VA. R.P.Z.A. P.V.B.
CHECK VALVt NO.1
CHECK VALVE NO.2
DIFFERENTIAL RELIEF VALVE
AIR INLET
CHECK VALVE
Closed Tight:
Closed Tight:
FAILED TO OPEN:
FAILED To OPEN:_
LEAKED:_
to
OPENED AT:
HELD AT:
Leaked:
Leaked:
OPENED AT: PSI
PSI
PSI
PRESSURE DIFFERENTIAL ACROSS CHECK
I
PRESSURE DIFFERENTIAL ACROSS CHECK7
PSI
PSI
I 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 ABILI S.
SIGNATURE Of TIFIE TESTER:
_qj
rf
h h
NOTE: TEST FORM MUST BIHCOMPLETED IN ITS ENTIRETY. INCOMPLETE TEST FORMS WILL BERETURNED.
Revised: 5/27/2010 e-mail: CCC@miamidade.gov web: http://www.miamidade.govtwater/cross-connection-backfiow.asp
77