□
DS
□
RPZ
□
FS
□
DCV
PURCHASE DATE
PARTS KIT
PARTS KIT
PARTS KIT
*NOTE : ALL REPAIRS / REPLACEMENTS MUST BE COMPLETED WITHIN FOURTEEN (14) DAYS
IV. APPROVALS
TELEPHONE NO. OF WITNESSDATE
DATE
DATE
DATE
SIGNATURE OF FINAL CERT. BACKFLOW PREV. ASSEMBLY TECH.
CERTIFIED TECH. NO.
SIGNATURE OF LICENSED TECHNICIAN CERTIFIED TECH. NO.
FINAL
TEST
BUSINESS TELEPHONE NO. WITNESS TO ASSEMBLY TEST
REPAIRS
NAME OF CERTIFIED BACKFLOW PREVENTION ASSEMBLY
TECHNICIAN (PRINT)
INITIAL
TEST
SIGNATURE OF INITIAL CERT. BACKFLOW PREV. ASSEMBLY TECH.
SIGNATURE OF REPAIRER
CERTIFIED TECH. NO.
CERTIFIED TECH. NO.
REMARKS :
□
ASSEMBLY FAILED
□
ASSEMBLY PASSED
□ CUSTOMER INFORMED
* I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OT THE ASSEMBLY
FINAL
TEST
□ CLOSED TIGHT AT ______ PSID □ CLOSED TIGHT AT ______ PSID
□ OPENED AT ______ PSID
CONDITION OF NO. 2 CONTROL VALVE : □ CLOSED TIGHT □ LEAKED
□
LOCKNUTS
□
SEAT
□
OTHER:
□
STEM /
□
CV ASSEMBLY GUIDE
□
DISC
□
RETAINER
□
CLEANED
REPAIRED:
□
RUBBER
□
SPRING
□
RETAINER
□
O - RINGS
□
LOCKNUTS
GUIDE
□
DISC
□
O - RINGS
□
SEAT
□
OTHER:
□
LOCKNUTS
□
OTHER:
□
CLEANED
REPAIRED:
□
RUBBER
□
SPRING
□
STEM /
□
CV ASSEMBLY
□
SPRING
□
STEM /
GUIDE
□
RETAINER
□
DISC
□
O - RINGS
□
SEAT
* REPAIRS
□ OPEN AT ________ PSID
□ DID NOT OPEN
□
CLEANED
REPAIRED:
______________________ PSID
□
LEAKED
□
CLOSED TIGHT
PRESSURE DROP ACROSS THE SECOND
CHECK VALVE IS :
______________________ PSID
□
LEAKED
□
CLOSED TIGHT
PRESSURE DROP ACROSS THE FIRST
CHECK VALVE IS :
CALIBRATED ON NEXT CALIBRATION DUE
CHECK VALVE NUMBER 1 CHECK VALVE NUMBER 2 DIFFERENTIAL PRESSURE
RELIEF VALVE
INITIAL TEST
□
RUBBER
□
CV ASSEMBLY
MANUFACTURER
II. TEST INSTRUMENT CALIBRATION INFORMATION
III. TESTS & REPAIRS INFORMATION
TYPE OF INSTRUMENT MODEL SERIAL NUMBER
CALIBRATED BY
MODEL SERIAL NUMBER SIZE
INCOMING LINE PRESSUREDATE OF INSTALLATIONLOCATION OF ASSEMBLY
ZIP
CONTACT PERSON AT FACILITY TITLE TELEPHONE NO.
NAME OF FACILITY ADDRESS
BACKFLOW PREVENTION ASSEMBLY
TEST AND MAINTENANCE RECORD
CITY OF PHILADELPHIA
PHILADELPHIA WATER DEPARTMENT
TELEPHONE NO.
REGISTRATION NO.
THIS FORM (79-770) MUST BE COMPLETED BY A CITY CERTIFIE
D TECHNICIAN
I. GENERAL INFORMATION
ORIENTATION
ACCOUNT OR METER #
SEND COMPLETED FORMS TO:
PWD INDUSTRIAL WASTE &
BACKFLOW COMPLIANCE
9001 STATE ROAD
PHILADELPHIA, PA 19136
TELE: (215) 685-8068
FAX: (215) 333-9453
E-mail: [email protected]
