CROSS CONNECTION DEVICE FIELD TESTING AND MAINTENANCE REPORT

Walnut Valley Water District271 S. BREA CANYON RD., WALNUT, CA 91789

(626) 964-6551 (909) 595-7554

METER SIZE

WATER SERVICE ACCOUNT NO. A

C

C

O

U

N

T

RETURN NO LATER THAN

NOTE: THE FOLLOWING TO BE COMPLETED BY CERTIFIED CROSS-CONNECTION DEVICE TESTER

(SEE REVERSE SIDE FOR INSTRUCTIONS)

TESTER'S NAME(PLEASE PRINT) TELEHPONE NO. ( )

TESTER'S FIRM

ADDRESS CITY ZIP

CHECK VALVE # 1 CHECK VALVE # 2DIFFERENTIAL

PRESSURE RELIEF VALVEAIR INLET VALVE

I

N

I

T

I

A

L

CLOSED TIGHT

PRESSURE DIFF. _______ lbs.

SEATS AT _____________ lbs.

LEAKED

CLOSED TIGHT OPENED AT _________ lbs.

DID NOT OPEN

T

E

S

T

F

I

N

A

L

T

E

S

T

LEAKED

SEATS AT _____________ lbs. OPENED UNDER 2 lbs. OR

OPENED AT _________ lbs.

OPENED UNDER 2 lbs. OR

DID NOT OPEN

OPENED AT _________ lbs.OPENED AT _________ lbs.

CLOSED TIGHT

SEATS AT _____________ lbs.

PRESSURE DIFF. _______ lbs.

SEATS AT _____________ lbs.

CLOSED TIGHT

NOTE TO TESTER: IF DEVICE FAILED ON THE INITIAL TEST, PLEASE LIST REPAIRS OR REMARKS ON THE REVERSE SIDE OF FORM

INITIAL TEST

I CERTIFY THE DEVICE LISTED ABOVE WAS TESTED USING APPROVED METHODS AND ________ PASSED/_______ FAILED

SIGNED TESTER NO. DATE OF TEST

FINAL TEST

I CERTIFY THE DEVICE LISTED ABOVE WAS TESTED USING APPROVED METHODS AND ________ PASSED/_______ FAILED

SIGNED TESTER NO. DATE OF TEST

CYCLE

IT IS THE RESPONSIBILITY OF THE TESTER TO VERIFY ALL INFORMATION REGARDING THE DEVICE'S LOCATION, TYPE, SIZE, MAKE, MODEL

AND SERIAL NUMBERS AND TO MAKE ANY NECESSARY CORRECTIONS HEREON.

IT IS THE RESPONSIBILITY OF THE OWNER OR CUSTOMER OF RECORD TO RETURN ALL COMPLETED FORMS. PLEASE MAIL FORMS TO WVWD OR EMAIL FORMS TO BACKFLOW@WVWD.COM.THE DEVICE LISTED HEREON IS NOT TO BE REMOVED, REPLACED OR RELOCATED

WITHOUT WRITTEN PERMISSION OF THE DISTRICT. IF A DEVICE FAILS, THE BACK OF THIS TEST FORM MUST BE SUBMITTED.

DISTRICT COPY

TYPE OF DEVICE

MAKE

LOCATION

MODEL NUMBER

SERIAL NUMBER

METER NUMBER

SIZE

DATE OF LAST INSPECTION

TEST FORM INSTRUCTIONS

RP (Reduced Pressure Principle Device)

A. Note pressure differential across the first check.

B. Check Valve No. 1 = closed tight or leaked.

C. Pressure differential relief valve = Record opening pressure, or opened under 2 lbs, or did not open.

D. Check Valve No. 2 = closed tight or leaked.

DC (Double Check Valves)

A. Check Valve No. 1 = Record pressure seated or leaked.

B. Check Valve No. 2 = Record pressure seated or leaked.

PVB (Pressure Vacuum Breakers)

A. Air inlet valve = Record pressure opened, or opened under 1 lb., or did not open.

B. Check Valve No. 1 (and/or No. 2) = Record pressure seated, or leaked.

(PLEASE LIST ANY REPAIRS MADE)

REPLACED:

DISC

DIAPHRAGM

FLOAT

SPRING

OTHER:

DESCRIBE:

R

E

P

A

I

R

S

CHECK VALVE

NO. 1

CHECK VALVE

NO. 2

DIFFERENTIAL

PRESSURE RELIEF

VALVE

AIR INLET

VALVE

CLEANED

REPLACED:

DISC

SPRING

GUIDE

HINGE PIN

SEAT

MODULE

OTHER:

DESCRIBE:

CLEANED

REPLACED:

DISC

SPRING

GUIDE

HINGE PIN

SEAT

MODULE

OTHER:

DESCRIBE:

CLEANED

REPLACED:

DISC(S)

SPRING

DIAPHRAGM(S)

SEAT(S)

O-RING(S)

MODULE

OTHER:

DESCRIBE:

CLEANED

REMARKS: