PL-11-2331 (2)RECEIVED 12/29/2011 08:05 3054E10121
Dec 29 2011 9:22 MRC Plbg. & Backflow 305 273 6181 page 1
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ARM, NN MU
MIAMFDADE
COUNTY
DEC 2 9 2011
MIAMI -DADE WATER & SEWER DEPARTMENT
METER OPERTATIONS & MAINTENANCE
CROSS - CONNECTION CONTROL UNIT
1001 N.W.11t STREET, MIAMI, FL 33136-2209
Phone (305)547 -3046 Fax (786)268.5485
BACKFLOW PREVENTION ASSEMBLY TEST REPORT FORM
ADDRESS OF DEVICE 1360 NE 103rd St
OWNER CONTACT: NEM InshallaUon !Affordable litigation
ONTEROFDEVTCE: Bianchi Frederdlc
PHONE: 305 6816322
ADDRESS OFowNER 1360 NE 103rd St
FAX 305 6616321
Z1P CODE:: 33138
NAME OF TESTER: ROBEtTO CDLI.AZO
CERTIFICATION #:H02387
PHOAE::305213 8100
TESTKRMAICE: MIDWEST
BUSINESS ADDRESS PD. BOX 833323 MM, FL
tdCDEL #.835 SERIALIt: 09091454
DATE LAST CAL ll15W11 SITE TUBE:
YES 1 NO
SERIAL #: 772935
HAZARD/SERVICE:
DATE OF TEST: 12/29/2011
IJNE PRESSURE: 64
PRESSURE STABLE: YES - NO
CHECK VALVE NO. 1
CHECK VALVE NO. 2
CHECK VALVE
Closed Tight:
Leaked:
FAILED TO OPEN:
PRESSURE PRESSURE D'FFERENTIAL ACROSS CHECK
OPENED AT:
OPENED AT PSI
REMARKS) REAM FOR FAILURE OF APPARENT):
r
REPLACED:
CHECK VALVE NO. 1
CHECK VALVE NO. 2
DIFFERENTIA!. REUEF VALVE
AIR INLET CHECK VALVE
Closed Tight:
Closed Tight:
FAILED TO OPEN:
Leaked:
PRESSURE
PSI
Leaked:
PRESSURE DIFFERENTIAL ACROSS CHECK
PSI
OPENED AT:
HEW AT:
OPENED AT: PSI
SIGNATURE OF CERTIFIED
NOTE: TEST FORM MUST BE COMPLETED IN ITS ENTIRETY. INCOMPLETE TEST FORMS WILL BE RETURNED.
Revised: 5/2712010 a -malt: CCC@lniamidade.gov web: www. mlarnidade .goviwasdtcross- connection.a;sp