Transcription of BACKFLOW PREVENTION ASSEMBLY TEST AND ... - …
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BACKFLOW PREVENTION ASSEMBLY TEST AND ... - …
DS RPZ FS DCVPURCHASE DATEPARTS KITPARTS KITPARTS KIT*NOTE : ALL REPAIRS / REPLACEMENTS MUST BE COMPLETED WITHIN FOURTEEN (14) DAYSIV. APPROVALSTELEPHONE NO. OF WITNESSDATEDATEDATEDATESIGNATURE OF FINAL CERT. BACKFLOW PREV. ASSEMBLY TECH. OF LICENSED TECHNICIANCERTIFIED TECH. TESTBUSINESS TELEPHONE TO ASSEMBLY TESTREPAIRSNAME OF CERTIFIED BACKFLOW PREVENTION ASSEMBLY TECHNICIAN (PRINT)INITIAL TESTSIGNATURE OF INITIAL CERT. BACKFLOW PREV. ASSEMBLY OF REPAIRERCERTIFIED TECH. TECH. : ASSEMBLY FAILED ASSEMBLY PASSED CUSTOMER INFORMED* I HEREBY CERTIFY THAT THIS DATA IS ACCURATE AND REFLECTS THE PROPER OPERATION AND MAINTENANCE OT THE ASSEMBLYFINAL 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 ASSEMBLYGUIDE DISC RETAINER CLEANEDREPAIRED: RUBBER SPRING RETAINER O - RINGS LOCKNUTSGUIDE DISC O - RINGS SEAT OTHER: LOCKNUTS OTHER: CLEANEDREPAIRED: RUBBER SPRING STEM / CV ASSEMBLY SPRING STEM /GUIDE RETAINER DISC O - RINGS SEAT* REPAIRS OPEN AT _____ PSID DID NOT OPEN CLEANEDREPAIRED:_____ PSID LEAKED CLOSED TIGHTPRESSURE DROP ACROSS THE SECONDCHECK VALVE IS :_____ PSID LEAKED CLOSED TIGHTPRESSURE DROP ACROSS THE FIRSTCHECK VALVE IS :CALIBRATED ONNEXT CALIBRATION DUECHECK VALVE NUMBER 1 CHECK VALVE NUMBER 2 DIFFERENTIAL PRESSURERELIEF VALVEINITIAL TEST RUBBER CV ASSEMBLYMANUFACTURERII.
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 certified technician i. general information orientation account or meter # send completed forms to:
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