PL-4-17-1029 BACKFLOW TESTMIAMI-DADE WATER & SEWER DEPARTMENT
METER OPERTATIONS 8 MAINTENANCE
MIAMI•DIADE CROSS -CONNECTION CONTROL UNIT
1001 N.W.11th STREET, MIAMI, FL 33136-2209
Phone (305) 547-3046 Fax(786)268-5485
BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM
ADDRESSOFDEVICE: 1490 NE 101 St, Miami Shores, FI 33138
OWNEROFDEVICE: Marc Alegre
OWNER CONTACT:
PHONE:: 863 557 7629
FAX:
1
ADDRESS OF OWNER: SAME
ZIP CODE::
NAME OF TESTER
CERTIFICATION #: EXPIRATION DATE:: PHONE::
2
Roberto Collazo
H02387 12/17/21 305 273 6100
BUSINESS ADDRESS: ZIP CODE:
BUSINESS NAME:
MRC Plumbing & Backflow Inc.
P.O. Box 833323, Miami, Fl. 33283
3
TEST KIT MAKE::
MODEL #:
SERIAL #:
DATE LAST CAL
SITE TUBE:
Mid -West
835
09091454
02/03/20
YES / NO
TEST PLEASE MARK: R.P X D.C. P.V.B.
MAKE OF ASSEMBLY: MODEL NO
SERIAL #:
SIZE:
WATTS 1919
86166
3/4"
HAZARD/SERVICE:
METER NO 20210691
By the POOI Pump
4
LOCATION OF ASSEMBLY:
INITIAL TEST: X ANNUAL TEST:
DATE OF TEST: 1 1 /2O/2O
METER READING:
SHUT OFF VALVE ft
SHUT OFF VALVEI1i:.
CLOSED TIGHT:
CLOSED TIGHT: -
LINE PRESSURE: 68
PRESSURE STABLE: YES
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: X
Closed Tight: X
FAILED TO OPEN:
FAILED TO OPEN:_
LEAKED:
N
w
�
Leaked:
Leaked:
OPENED AT:
PRESSURE DIFFERENTIAL ACROSS CHECK
PRESSURE DIFFERENTIAL ACROSS CHECK
HELD AT:
OPENED AT: 2.8 PSI.
PSI
PSI
9.8 PSI 1
2.0 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: — --
w
Q
REPLACED:
REPLACED:
REPLACED:
REPLACED:
a
w
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:
`
ca
W
F,-
AT: A:
HELD AT:
W
Leaked:
Leaked:
PSI
PSI
—
PRESSURE DIFFERENTIAL ACROSS CHECK
PRESSURE DIFFERENTIAL ACROSS CHECK
OPENED AT: PSI
PSI
I 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 ABILITIES.
c�6erty L7C11!li o
DATE: 1 1 /20/20
SIGNATURE OF CERTIFIED TESTER: Device Passed X Device Failed
—