Transcription of BACKFLOW PREVENTION ASSEMBLY TEST AND ... - …
1 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.
2 TEST INSTRUMENT CALIBRATION INFORMATIONIII. tests & REPAIRS INFORMATIONTYPE OF INSTRUMENTMODELSERIAL NUMBERCALIBRATED BYMODELSERIAL NUMBERSIZEINCOMING LINE PRESSUREDATE OF INSTALLATIONLOCATION OF ASSEMBLYZIPCONTACT PERSON AT FACILITYTITLETELEPHONE OF FACILITYADDRESSBACKFLOW PREVENTION ASSEMBLYTEST AND MAINTENANCE RECORDCITY OF PHILADELPHIAPHILADELPHIA WATER DEPARTMENTTELEPHONE FORM (79-770) MUST BE COMPLETED BY A CITY CERTIFIED TECHNICIANI. GENERAL INFORMATIONORIENTATIONACCOUNT OR METER #SEND COMPLETED FORMS TO:PWD INDUSTRIAL WASTE & BACKFLOW COMPLIANCE 9001 STATE ROAD philadelphia , PA 19136 TELE: (215) 685-8068 FAX: (215) 333-9453E-mail.
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