PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SW Ogden Lane, Port St Lucie, FL 34983

Effective 01/24/17 Page 1 of 1 PSLUSD Doc. No. 123

Backflow Prevention Assembly Test ReportFacility NameMeter Test Report Due

Schedule Code

Assembly ID Account No. Service Address Assy Location Location No. Contact Name Map Page

Telephone

Assembly Info (Replacement/Correction)SNMfrTypeSizeModelInstall DatePermit No.Hazard LevelHazard Type

Protection

Line Pressure at Time of Test REPORT OF TEST RESULTS Approved BFP

Initial TestPass

Fail

Check Valve #1 Check Valve #2 Relief Valve PVB/SVB Shut Off Valves

Closed Tight

Leaked

#1 #2Air Inlet Opened at PSID

Did Not Open

PSID Held Check at

Opened at

PSID

Did Not Open

Held at

PSIDClosed Tight

LeakedLeaked

Held at

PSID

Closed Tight

Leaked

Cleaned

REPLACED

Disc

Spring

Guide

Seat

Hinge Pin

Diaphragm

Module

Cleaned

REPLACED

Disc

Spring

Guide

Seat

Hinge Pin

Module

Cleaned

REPLACED

Disc

Spring

Guide

Seat

O-Ring(s)

Module

Cleaned

REPLACED

Air Inlet Disc

Air Inlet Spring

Check Disc

Check Spring

Float

Diaphragm

CLEANED

REPLACED

REPAIRED

OTHER

Repairs

Other/Notes

Final TestPSID

Closed Tight

PSID

Closed Tight

Opened at Air Inlet PSID

CK Valve PSID

Closed Tight

PASS

Initial Test By

Final Test By

Repair By

Certificate Date Gauge No. Time In Time Out Company Telephone

PSIDTHE ABOVE REPORT IS CERTIFIED TO BE TRUE

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SW Ogden Lane, Port St Lucie, FL 34983

Effective 01xx17 Page 1 of 1 PSLUSD Doc. No. 48

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

EOR/EOR Rep Date

To be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.com

Flushing Report

Pass Fail

Date Lines TestedGallons

Per MinuteMinutes Flushed

GallonsFlushed

Number of Pigs Used

Number of Pigs Retrieved

Residue in Bucket? Yes No

Water

Sewer

Reclaimed

Total Gallons Flushed

Pressure TestTo be completed by the Engineer of Record (EOR)/EOR Rep. and e-mailed to UtilEng@cityofpsl.com

Project Name

PSLUSD Project No.

Engineer of Record (EOR)

Contractor

Allowable Leakage Formula:

Location/Limits of Test

Water Wastewater Re-claimed Water

Pass Fail

Start Time End Time

EOR/EOR Rep Date

148,000

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Print Signature

Inspector

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01xx17 Page 1 of 1 PSLUSD Doc. No. 73

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

EOR/EOR Rep Date

To be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.com

Fire Hydrant Flow Test

Pass Fail

HYRDRANT REPAIR KIT RECEIVED:IF NOT, TEST FAILS UNTIL KIT RECEIVED

COEFFICIENT NUMBER*COEFFICIENT NUMBER REMAINS AT 0.88

DIAMETERDIAMETER OF HYDRANT DISCHARGE (TYPICALLY 2.5")

STATIC PRESSUREPRESSURE PRIOR TO FLUSHING HYDRANT

RESIDUAL PRESSUREPRESSURE DURING FLUSHING OF HYDRANT

PITOT PRESSUREPRESSURE READING ON PITOT GUAGE

RESIDUAL FLOWRF=29.83 X (CN X DIA TO THE 2 POWER) X (√PP)

FIRE FLOWFF= RF X ((SP-20) ÷ (SP-RP)) TO THE 0.54 POWER

*COEFFICIENT NUMBER IS BASED ON SHARPE SQUARE EDGE INLET TYPESCN= COEFFICIENT NUMBER DIA = DIAMETER

PP= PITOT PRESSURE RF = RESIDUAL FLOW FF = FIRE FLOW

COMMENTS

SP = STATIC PRESSURERP = RESIDUAL PRESSURE

YES NO

Print Signature

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01/20/17 Page 1 of 1 PSLUSD Doc. No. 93

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

EOR/EOR Rep Date

To be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.comWire Continuity & Electronic Marker Verification Test Report

Pass Fail

Water Main Tested

Force Main Tested

Re-Use Water Main Tested

All Trace Wire Tested

All Electronic Markers Tested

Pass

Pass

Fail

Fail

Limits of Test

Comments

Print Signature

City of Port St Lucie

PSLUSD

Phone (772) 344-4320Email: UtilEng@cityofpsl.com

Utility Systems Department

900 SE Ogden Lane, Port St Lucie, FL 34983

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

Telespection Company

Verified Running Water Downstream for Each Test

page of

Date Tested

BeginningMH#

EndMH#

SVCL/R FT

SVCL/R FT

SVCL/R FT

SVCL/R FT

SVCL/R FT FailPass

OtherProblemFootageDIP

SVCL/R FT

SVCL/R FT

SVCL/R FT

SVCL/R FT

Other Problem(s):A Excessive Sand/SiltB Leaking ServiceC Damaged PipeD Bad Joint

Effective 01/18/17 PSLUSD Doc. No. 105

EOR/EOR Rep. Date

Yes No

Telespection Test ReportTo be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.com

Print Signature

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01/12/17 Page 1 of 1 PSLUSD Doc. No. 108

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

EOR/EOR Rep Date

To be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.com

Deflection Test Report

Pass Fail

Date Tested:

Equipment Used: Mandrel

To Structure Pass or Fail

Calibrated Laser Camera

Start Time: End Time:

From Structure

Date Calibrated:

30 Days After Final Backfill?

Main Diameter Main Length

Print Signature

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01/12/17 Page 1 of 1 PSLUSD Doc. No. 109

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

EOR/EOR Rep Date

To be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.com

Infil/Exfil Test Report

Pass Fail

Allowable Leakage Formula:Gravity Sewer 50 Gallons/Per Day (24 Hours)/Per Inch Diameter/Per Mile (5280 Feet) Wet Well & Interceptor - 0 Loss

Structures Tested Structure Diameter/Gal. Structure Depth Allowable Per Hour Test Allowable

Main Tested Main Diameter Main Length Allowable Per Hour Test Allowable

Services Tested Service Diameter Service Length Allowable Per Hour Test Allowable

Infil

Exfil

Start Time:

End Time:

Total Test Allowable Actual Leakage

Print Signature

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01/18/17 Page 1 of 1 PSLUSD Doc. No. 110

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

Date

Pump Station Start Up Test

Pass Fail

Diameter

Depth

Voltage

Phasing

Full Load Amps

Pump HP

FPL Meter

Design GPM

Design TDHPump #1 Pump #2

Actual GMP

Actual TDH

Pump Manf/Model

Generator on Site

Repair Kit Turned Over

Plant Able to Communicate

Plant Can Read Guages

Yes

Yes

Yes

Yes

No

No

No

No

Start Up Fails Until Kit Turned Over

Attendees:

Deficiencies:

Signature

EOR/EOR REPPrint

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01/20/17 Page 1 of 1 PSLUSD Doc. No. 110

Pump Station Start-Up WorksheetA = The measurement from the top of the rim of the station after ending the pump draw down test.B = The measurement from the top of the water to the rim of the station before starting the pump draw down test. C = The measurement from the rim of the station to the center of the pressure gauge.D = The diameter of the station.PSI = Reading of pressure gauge.

Formula:

Pump #1 Pump #2

A =

B =

C =

D =

PSI =

inches

inches

inches

inches

feet

feet

feet

feet

A =

B =

C =

D =

PSI =

inches

inches

inches

inches

feet

feet

feet

feet

1. (A ft - B ft) x (D ft x D ft) x 7.481 x 0.7854 = Volume Displaced in Gallons2. A ft - C ft = Total Static Lift (TSL)3. PSI x 2.31 = Dynamic Head Pressure (DHP)4. TSL + DHP = Total Dynamic Head Pressure (TDHP)

Pump #1

1.((A ft) – (B ft) x (D ft) x (D ft) ) x 7.481 x 0.7854 = Volume Displaced

(A-B ft) x (DxD ft) x 7.481 x 0.7854 = Volume Displaced

2. (A ft) –/+ (C ft) = Total Static Lift (A-C if pressure gauge is below rim, A+C if pressure gauge is above rim.)

3. (PSI) x 2.31 = Dynamic Head Pressure

4. (TSL) + (DHP) = Total Dynamic Head Pressure

5. (PSI) x 2.31 = + Static Lift = Shutoff Head (Not for low pressure) (after start up, close valves in valve pit and pump against them for PSI)

Pump #2

1.((A ft) – (B ft) x (D ft) x (D ft) ) x 7.481 x 0.7854 = Volume Displaced

(A-B ft)(A-B ft) x (A-B ft) x (DxD ft) x 7.481 x 0.7854 = Volume Displaced

–/+ (C ft) –/+

(PSI) x 2(PSI) x 2.31 =

2. (A ft)

3. (PSI)

4. (TSL) + (DHP) = Total Dynamic Head Pressure

5.5. (PSI) x 2.31 = + Static Lift = Shutoff Head (Not for low pressure.)(after start up, close valves in valve pit and pump against them for PSI)

= Total Static Lift (A-C if pressure gauge is below rim, A+C is pressure gauge is above rim.)

Dynamic Head Pressure

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SE Ogden Lane, Port St Lucie, FL 34983

Effective 01/18/17 Page 1 of 2 PSLUSD Doc. No. 191

Project Name:

Type of Station:

Pump Station Inspection

1. Valve Vault at Correct Elevation

2. Pedestal at Correct Height

3. Red Light Visible from Roadway

4. Wetwell at Correct Elevation

5. Fall Protection Installed

6. Odor Scrubber Installed

7. Pump Out Connection is Correct Size

8. Dust Cap has a 1/4" SS Ball Valve Installed

11. Pipe Supports & Uni-strut Correct Material

10. Pressure Reducer Installed & Correct Material

12. Uni-strut Caps on Ends

9. Pipe Support Installed & Correct Material

13. All Components Installed on Pedestal/Uni-strut

13a. Components at Correct Height

14. Correct Materials for City/County

15. Hose Bib Installed Correctly

16. Seal Offs in Place

17. Hose Bib Installed & Secure

18. Water Meter & RPZ Installed

19. Fence Installed with Correct Materials

20. Fence Installed in Correct Location

Project No.:

Station No.:

Y N N/A

Effective 01/18/17 Page 2 of 2 PSLUSD Doc. No. 191

21. Lift Station ID Sign on Fence in Correct Location

22. Antenna in Correct Location

23. Flood Light Installed & Aimed Correctly

24. Driveway & Generator Pad Correct Size

25. Visqueen & Rock Installed at Correct Depth

26. Site Graded Sloping Away from Wetwell

27. First Manhole Inside of the Fenced Area

28. 12' x 48' Area for Vac Truck Within

29. 10' of the Center of Wetwell

30. Bollards Installed Where Required

31. All Piping above Ground & Inside Wetwell

32. Painted with Proper Paint & Thickness

Comments:

Photos:

EOR/EOR REP Date

Y N N/A

Print Signature

PSLUSD

City of Port St LucieUtility Systems Department

Phone (772) 344-4320Email: UtilEng@cityofpsl.com 900 SW Ogden Lane, Port St Lucie, FL 34983

Effective 06/22/17 Page 1 of 1 PSLUSD Doc. No. 111

Project Name

PSLUSD Project No.

Engineer of Record

Contractor

EOR/EOR Rep Date

To be completed by the Engineer of Record (EOR)/EOR Rep. and E-Mailed to UtilEng@cityofpsl.comUtility Work Completion Inspection

Pass Fail

Initial Inspection Date Re-inspection Date

All Grading Complete

Valve Pads Level

Discs Correct

Valve Lids Painted Correct Color

Valves Turn Freely

Electronic Marker System- Balls in Place

Sample Points Removed & Plugged

Fire Service has hi/lo Flow Setup

Fire Service has Chains & Locks

Mains have Cover in Swale Aeeas

Reflective PavementMarkers in Place

All Necessary Valves Opened/Closed

Pumpstation Fence has no Damage

Fence Gates Open/Close Smoothly

All Padlocks in Place

Interceptors at GradeInterceptors Have Correct LidsInterceptor Lids Labeled Correctly

RPZ Plumb & Stable

Meters Set

Meters LockedAll Meters Have Separate Curb StopMeters Over 3" have hi/lo Flow Setup

Blow Off Assemblies CorrectFire Hydrant Paint Not Scuffed

Fire Hydrant Meets ClearancesHydrant Chains Intact

Air Release Valve (ARV)

ARV Lid Painted Correct ColorARV Lid Doesn't Hit Valve

Landscape/Tree IssuesConcrete Work has No Damage

Manholes at Correct Elevation

Manholes are Clean

Manholes Have Correct LidsClean-outs in Place with Covers

Comments

Attendees

Y N N/A Y N N/A

Remove Plug from Sanitary Sewer after Passing Inspection