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 [email protected] 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: