Form Qpctmr - Quarterly Physical Connection Test & Maintenance Report September 2013

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Physical Connection Permit No.:
-WPC
QPCTMR 09/13
NEW JERSEY DEPARTMENT OF ENVIRONMENTAL PROTECTION
Quarterly Physical Connection Test & Maintenance Report
st
nd
rd
th
1
Quarter
2
Quarter
3
Quarter
4
Quarter
Instructions: This form is to be completed for each test of each
approved valve. It is to be mailed to the Supplier of Water
and Local Administrative Authority within 5 days of each test
01/01-03/31
04/01-06/30
07/01-09/30
10/01-12/31
and inspection performed by a Certified Tester. These forms
shall be kept at the facility for a period of 5 years (N.J.A.C.
Date of test
/
/
7:10-10.2(f)) and be exhibited upon request.
To:
From: (Name of Permit Holder)
The backflow prevention device identified below has been tested and inspected as required by N.J.A.C. 7:10-10.6
and is certified to be in compliance with this regulation.
Description of Valve
Location of Valve
Manufacturer:
RPZ
DCVA
Model Number:
Size: _____in.
Serial Number:
Comments and Notations:
Test Kit Serial #
PRESSURE TEST
INTERNAL INSPECTION
______________
REDUCED PRESSURE ZONE ASSEMBLY
DOUBLE CHECK VALVE
Calibration Date
ASSEMBLY
DOUBLE CHECK VALVE
st
nd
st
nd
_______________ 1
Check
2
Check
Relief Valve
1
Check
2
Check
Initial Test
Closed Tight
at
Closed Tight
at
Opened at
OK
OK
psid
psid
psid
Leaked
Leaked
Passed
No. 2 Shut-off Valve Closed Tight
Did Not Open
Failed
Failed
Failed
Leaked
By-pass Used
Repairs &
Materials Used
Test After Repair
Closed Tight
Closed Tight
Opened at
OK
OK
& Assembly
psid
psid
psid
The Results Shown Above are Certified to be True
Witnesses to test and inspection
Certified Testers Name:
Name:
Title:
Certified Testers Signature: __________________________
Representing:
Certifying Authority:
Name:
Title:
Cert. ID #:
Exp. Date:
/
/
Representing:
Tester Phone No: __________________________________

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