Cross Connection Control Devices Test Report Form
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1Cross Connection Control Devices Test Report
44865 Loudoun Water Way Ashburn, VA 20147
Tel: 571.291.7880
Fax: 703.729.9494
Residential
Owner:
Commercial or Multi Family Complex
Street Address:
Location of Device:
Protection for:
Type of Device – RP
DC
PVB
SVB
Serial Number:
Manufacturer:
Model Number:
Size:
Line Pressure at Time of Test _______________PSI
Pressure Drop Across First Check Valve _______________ PSI
DIFFERENTIAL
PRESSURE VACUUM
CHECK VALVE #1
CHECK VALVE #2
PRESSURE RELIEF
BREAKER
VALVE
1._____ Leaked
1._____Leaked
Opened at _______lbs.
Air Inlet
Initial
Reduced Pressure
Opened at _________PSI
Test
2._____Closed Tight
2._____Closed Tight
_____Did Not Open
_____Did Not Open
_____ Cleaned
_____ Cleaned
_____ Cleaned
Check Valve
Replaced:
Replaced:
Replaced:
_____ Closed tight
_____ Valves
_____ Valves
_____ R.V. Replaced
_____ Did Not Close
_____ C.V. Assembly
_____ C.V. Assembly
_____ Disc. Upper
_____ Seat Disc
_____ Seat Disc
_____ Disc. Lower
R
_____ Cleaned
_____ O-rings
_____ O-rings
Diaphragm, Large:
E
Replaced:
_____ Springs
_____ Springs
_____ Upper
P
_____ Valves
_____ Gaskets
_____ Gaskets
_____ Lower
A
(Top)
_____ Disc.
_____ Retainer
_____ Retainer
Diaphragm, Small:
I
(Bottom)
_____ Disc.
_____ Stem/Guide
_____ Stem/Guide
_____ Upper
R
_____ Springs
_____ Poppet
_____ Poppet
_____ Lower
S
_____ Retainer
_____ Other, Describe
_____ Other, Describe
_____ Spacer
_____ Stem
_____ O-rings
_____ Guide
_____ Washer
_____ Poppet
_____ Other, Describe
_____ Other, Describe
Opened at
Final
____
_____
____
Closed Tight
Satisfactory
Closed Tight
__________lbs.
Test
Reduced Pressure
NOTE: All repairs/replacements shall be completed within ten (10) days.
REMARKS:_______________________________________________________________________________________________
_________________________________________________________________________________________________________
I hereby certify that this data is accurate and reflects the proper operation and maintenance of the unit.
Certified Testing Company:____________________________________________________ Business Tel #: _________________
Initial Test By:_______________________________Certified Tester No.________________ Date: ________________________
Test Kit Used: Serial Number______________________________
Last Calibration Date ______________________
Repaired By:________________________________ Certified Tester No.________________ Date: ________________________
Final Test By: _______________________________ Certified Tester No. ________________ Date: _______________________
Test Kit Used: Serial Number______________________________
Last Calibration Date ______________________
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