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
ORIENTATION ACCOUNT OR METER #
I. GENERAL INFORMATION
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
INITIAL TEST

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 : □ DID NOT OPEN
______________________ PSID ______________________ PSID
□ CLEANED □ CLEANED □ CLEANED
REPAIRED: REPAIRED: REPAIRED:
□ RUBBER □ SPRING □ RUBBER □ SPRING □ RUBBER □ SPRING
* REPAIRS

PARTS KIT □ STEM / PARTS KIT □ STEM / PARTS KIT □ STEM /

□ CV ASSEMBLY GUIDE □ CV ASSEMBLY GUIDE □ CV ASSEMBLY GUIDE
□ DISC □ RETAINER □ DISC □ RETAINER □ DISC □ RETAINER
□ O - RINGS □ LOCKNUTS □ O - RINGS □ LOCKNUTS □ O - RINGS □ LOCKNUTS
□ SEAT □ OTHER: □ SEAT □ OTHER: □ SEAT □ OTHER:
FINAL
TEST

□ CLOSED TIGHT AT ______ PSID □ CLOSED TIGHT AT ______ PSID

□ 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
REPAIRS

SIGNATURE OF REPAIRER CERTIFIED TECH. NO. DATE SEND COMPLETED FORMS TO:
PWD INDUSTRIAL WASTE &
BACKFLOW COMPLIANCE
9001 STATE ROAD
SIGNATURE OF FINAL CERT. BACKFLOW PREV. ASSEMBLY TECH. CERTIFIED TECH. NO. DATE PHILADELPHIA, PA 19136
TELE: (215) 685-8068
FINAL
TEST

FAX: (215) 333-9453

E-mail: CCC.BLS@PHILA.GOV
SIGNATURE OF LICENSED TECHNICIAN CERTIFIED TECH. NO. DATE