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