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HomeMy WebLinkAboutPermit Correspondence 1986-11-24 BACKFLOW PREVENTION DEVICE' ;JEST AND MAINTENANCE RE~ORY ~,,: We have made the following test. as required by the Oregon Administrative Rules 333-61-070 ,':3 ct. V;..: fJ , '. .. ADDRESS OF DEVICE: . /565 5::"';7." /1, ,,<;/7;::;1) -. . NEW rn/EXISTING ~p.-, LOCATION OF DEVICE ON PROPERTY:' .tf>/<,7' Sd)C' /h ''IIL/'. ():;;,,:;..; tZ'.. /)/l?cJJ' "., " TYPE OF DEVIC".,/l1J1..1 ~tl". ,(',0/ (",K ".....'.. qZE.~:/ <", SERIAl' NO.:' -<:: ,;24/,-7 .,>. .. '.' . DEVICE SERVES OR ISOLATES- ,'J./AA'1'u '.,/~//--rT.e "'.'S'tf.~;7/.>tV;~.';'"r'.. --". ',;,,<' 'k~,'~;;:,.';\ > .;:,::"-:-,,,.-:,-, .." " -. ;..' l ,~ ".; i ! I f I , CHECK NO.1 :. .. " , Test . Lea ked 0 Before' , 'c~osed.'csY' Repa i rs )1 ght ;, Test. Closed After . , 0 Repa i rs 'Tight , .... " New .. Materials . .-. . a'nd -' ._i_ ! Repa i rs , Made ." Remarks: .. .,. " .., ,.' N"O' '';'1'..,.. ',.'.. . ' '-~--: . ~, '. ;'. -,.....;, ' P .S..I ,.': ' ,.,. Differential. "'~-.:':i;t. :', " ;.-' P:S. I';," .':," DifferE!ntia1. '. ;' .:'~, -,~~/!:' . .. . .' . ',r' ,......,-..., ~ ..... :..- ~~'--;' ,-,~ .~:~ ..:. ': : ":: 1'-\~: .. . "':,.;:.- -. '~." " . " "0-< , :",,',', ..t,':--, '-' - I THE ABOVE TEST HAS BEEN COMPLETEO . ' : : .~ DIFFERENTIAl:, PRES.' RELIEF. VALVE.,.''':' Openedat'''7 , 1bs{< . Differential:, "........' ~. 1 :"_ Opened :~e':s 1b's> , Different i a 1 '.,.. '." ,:1 . . . R~lief:po~{'; . has approved' 'air-gap:.., . , . .- :~~"~~'~'.':'~ 'Yes 0,< .': .' ~"":'. - ;~ '. '.' No D".'" : .' ... :.:~~:~t:~., '".~ '-,'--' . , :~" ~)_i: ".:.. . ~~. ;;,~,:;"~~~<.,,~..- ::_.'?'.:'-, ~ '. CHECK..NO> 2 ' .. "....... ;......: .-r':--:f-J,,:';{.: ,.:. . ,.... {,,- ;:.>_:~ ',~ ;<.-'~, \':': NO'<"2~"~;" ",":.:- 1"':'~ - < ~ .~...: ':L'ea'ked ,;' 0.. 'P: S~I/'-.' .;<~,; ~.,:",~- ,1..,. , ' .., Differential: ,'<c 1 osed :Q/" ,,"/-;;1. /5 J >, ::Ti ght !", '"." . '~. '~~:~,'..' '<'",::;t ~ " "'_. .--, . ~ - " .~. ~ ... t<'-'!:. .~-- .;\'';'' =,~. 'C~osed':D ,T1ght. :, 1''' 't.. . _,' ,~ " ,.', .-...._." , ".~ ~-- , , ;:~~~~if ,'.' ::.... ','- . ".', ..... . :-,~~~:. <. "- ,- " ,..: ... . .'. -t,. ~ .:;,?;~t;l/;i;: , t' I:. Repa i red by: Date:>:" " ,~,. i~-~--t:::.:~. :",:{:~2YiE't~{;q :' . FIRM NAME" .~"..; ">:\,-~;"T':::-;" ..:":~'r/",~""': . ADDRESS"": I ')(P~ :- t" 1\', ~:'..')rf{) ".'. '..:.', ",~.':,,:}',:''''.' SIGNATURE' OF DEVICE OWNER OR ,REPRESENTATIVE' "~"':'~ .1- . . l" p:.S: I':'.."", Di fferentia 1.' '. ",_. ..:.~ :~.',~l.t!.~<~~;, "' (:~" '".,,: ... '.-:'" " !:~~~;::~:~,{:~:")\: ,...., ,<",-.",.PRESSURE TYPE,..,.~".. ,:,,-.~,, "':'VACUUM '1REAKERS"~":Y"." ~.""::',,,:,,:: I _";"~~'_:,~:,,~ '" Air 'Inlet.., ." Check, Valve ". ,'. ,':,',' : :.>~>.::. '. :;~';:'Opehed :~t\:: " :(.~~. .',:_ .,.i~i.~~ , . - "Gauge' Readi ng'" '::Gauge Readi ng , ' He1d"at: . '.' ~. .. _...~~.~..':; ;-'. " , , ..:,..:. ..,. . ".,-",.:. .. ", :,~ " Did not~p;nO -- ,- . ;<"Opened' ~t'~. . ~....!l. '. 't" - ":~~': _~ Leaked 0 ,-~ .:->' .. .'" ~ '.';, " .. He1da.t.,;,;.' "'. , . .', ',Va lve,,1.2"~aliove" hi ghesthead. :'~"'" "., .y' .'0'" ",'N. 0 '..' ,,' ",.,.;:.. ,,'-.:.. es' , ,~, 0 '.~, ..-.,' ." ..\ : " ,: ,,',. -'::;!'. -. ',;.:' . . :;.. .,. ,., Double Detector ":,'" ':- 'Checkl~va1ve meter ", ':', ; :. _..' _ ~4. ' 'Reading ,pre')e'st.. . "'" . "- ,. After'Test.;:,." ... "". 'After"Fl ushi ng" Tested by:.73,," J/'<~/i,I's,'^-.1 Certification/No.: ,:,' ~-, 7 Date' ,.,/../ ':r C/ \..' ~ 31..3052 RevIsed 2-85 . '. ~~i\~l>:"~~~'>" ' ,. .<.,f~f/:.' .. .. ...',;:';,-" . , ., .~. :5:.3 .: .'_:...,:~: .'~,. :-.";:~_< ":,< ": .,"~, _. l. ~- '.,..:..i'./i;'" ". ,o?-.?', "::;;; ":.".~ ,;:;-' " . ":~f':';':-:V ::.:" ,'. r:L,IV"M"j.-.,'" ,;:..,,"dJ>' ,..'.,.," , , , , . > ~ t~., -._.c-~=''''' 47"'J;~Q:l!77'(Y";'Z~<n~-~\". ~,. . . ,~. '. ' " ~;;':', ,/,~, \" .~~. 1", .;, ..;....'1;. ..... SPQllGFIELD UTILITY BOARD .iL P. O. Box 300, S~ngfield, OR 97477, Phone 746..~' WATER DEPARTMENT BACKFLOW PREVENTION INSPECTION ..~ ----.:-. --. ...~----:-7:" ODate of inspection //. d 0/ - k<::: Inspector /;.;,// ;::,.,,;77 Name of organization(' ..1,",..:J,/,I,U~ IA.2L- Servi ce address / ~C; 0 c:; .<~" '4" ~/:. Mail ing address Telephone '/'/;70 YJ. '7 Owner.or rep Account #,"&0 ./~0;"cL'-6cation # 3k'(:. Ileter size /" flake li<1 ;".".. Laca t i on A ~ /;C" (' n <'lJ ,1/ _ _, _ >.~. /); C7 /...~. Serial number ;; j,) /c/o':::' Company number. t., :<"V::l Read /) / ~/ j Working: Yes____ No /0... :'of / Lawn Irrigation =-</1 Type device: Existing Reqyired''''''''- I Size of line on property./'/" ---- I .ABV--6" above: Yes../.' No I DCV'A:Drain to-dayl ioht l2" clearnce. 1 PVB: 1?~ii6ove '---- ----I ~ ~ I Fire Protection Size of fire line Account# Type fire system: Wet Dry Type device on fire line-- ---- Ser.no. Ilake "lode 1 no. Si ze Device required Cross..Conn. I Cross..Conn. Exists Device I Exists Device Comments YeslNo Recom' d. I Comments YeslNo Recom'd. Kitchen I Air washers I I I Utility sinks I Aspirator med. I I I Rest rooms I Chem.feed tanks I Water cooled equip. I Chlorinator I I 1 Refrigerators sys. , Dishwasher I I I Sewer lines 1 Drinking fount. I I I o Swillllning pool I Photo devel'q. 1 I I Lab equip. I Deterg.dispenser I I I Boil er I Floor drains I I I Steam lines I Ice maker 1 1 I Hose bibs I SteBm cleaner I I I ~Je 11 s on prop. I Steam table I I I .i Shampoo basin I Wash tanks I I 1 , I H20 boost. pumps I Air ga p 1 I I Sewer lift pump I Other I 1 I Plating tanks I Other I I I -Comp;,'essed-a iT I Other I 1 I REQUIRED BACKFLOW PREVENTION ON MAIN lINE: Reduced pressure principle backflow preventer Double-check valve assembly~ ---- Pressure Vacuum Breaker Atmospheric vacuum breaker____. A Plllnf\lIlr. D~QIA.lI....T<' Q~nIITI)~n FROM TII~ rTTV f'I~ <'OQHI(;nrl n PRlOR Tf"I 1I1~1'~1 I WOI,' Recommended Location JI 7~".9 ../.-/../7;;;...- , 1/') . J.....- / / ;.'~ :::i... ; . Requil'ed to he installed in: 10 days____ 30 days....x:.. fiO days____ ' Oregon State Health Division rules require water service to user's premises to be discon.. tinued where existinA or potential cross..connections are located on the user's premises until an approved backflow prevention device is installed. Rt.MAKK::': , O~. /,,(1. /1 ~l/''')'''A--..J;;l- ,.'.J.:.;. r, ,.-7_ -;::: /;,'/ ,<~A// .J /, .-~. . ,,~..., ,~ '~~/'. '/ / ., ~ ",....7~,. It_I" ,/ ,',,/ .....,..1,/..::rF", _ -,''''_' .?..... . " ,-", .....', "I;...~',// r,t:. .'iJ........-:.r ,~?/., ",:;'-7-/;;,,~ --7--:_.._ {/ J /r'//L/ el ... )ri A .'/: i '1 47 /Zc /"') ,-i ,~",- .""" (zls/p ~ ~{~'7'__ ~ /~ (,<..)04 kl:-' c:?l^-- L.( 11$ /f7. ?'f// /7/;'; i.4 (Jq/vaMIJc..ol c-v ('rf{ -MY'< i!cua ecfr Ot<-<7, ---;;r: 6'f7J~ Vi cv.J~ ~ crv-<' ~o -'-I J dd~ '.;:~.:'"",..:,' , ':',;~1f~~<:~FLO~P.~~,~~~DO~; D,~VI~~J:~Ig5T, AN~ ,MAINTENAN~E R~ORy ~ :i', lie, h~~Y~~~~::;'~~~/:~~,~,l:0,~~~,g':4~:}~~~~~,u',~;:r,:/:~~.~~~::,::,~~:inist~a~,i~~'~,~Ules 333-61,-070 . 3ct ,V _ rJ ~. :',' ' , ADDRESS OF DEVICE:' / ~ 6$' 50&177-1 11 -' <;,?~t}, . ' NEW ur;XISTING (1);:- ~:-:,~:, LOCATION"OF'DEVi'CE"ON PROPERTy;;ifi'~"T":s~i?"..; 'O/h- 'j1):,6:-."C~;>,,~/;2 fY j?t./J ' ;~::; TYPE 0F.."DEVICE:r,',:~r,.,/)1J1-16?;:~y('A.cc-k..'''>,'';.:;?;~',''.;'-;'., .,.-,' ''lm:'_/ " SERIAL NO.:' C' 7-41,-; ij~ ~:DEVIC~ SERVES OR:ISOLATES ':'lJ;;':1'uf"/~/l~j,(:!, '<;"tr/l'tV ' , ..' . . . . ." '. -', \~~,,' :<':::":~;"<CHEC~'NO.., 1 '. ., '. :~P'~f,' .:.,..::.,.~ . ,t.. .0 ,...,. . - . ; ~~-~. .,' ..-. t/R; -r',. 'f, , ;'. ~I, . 1-~ ;'-r ~~u~. :;~:~, ..'.' ~~~.:~ ,.;;; , , , ' ,'~. \:.',' ,...,," , F:'. .'r '. " ;I.~'\. r ~':.:"" , f.:~:.~i'. , i. ,.~ " , ~ , . . ,,-' " ". ~.:":: :,:. , ' :~~. ~ " .::;; ...- Test ,.. :::." Before ~L:, Repa i r~.':~.. " ':..:.',);,t ;.rt.,.:-;..~.-'- Test '~~.~J>:/. .......',;.,1 After;',~" Repai,rsf . ,. '" --::. : . .;~" <~., ,...., It : .~. .'[., New .' .::'~' Mat~r:i a 1 s .:, '~"':~:"'(; ,.~" and "c: ";.~~: . ..,....:.~......(... Repa i rs,;:~ ~". Made.".) ;' .f'~:,~~~\~,/~' ;,leaked 0 :"".".!;';.' . .'. . ..' ,~ ;'C~osed [S(' "Tlght"" .' ..: :- ~ -; ,J<' ..:" 'Closed:' , ;;Tl'9ht'.<:,D. ' " ",,". ..;;'~ ':-i";.')?::~':" . '- '. ~ , ~. . .. ~ ".: "~; ..;. :._;':~:~..: ,~.... . ..:~ : ~~iS~;'~' ~'.~:~:{ :-:/" . .:. ,~;~~".~:~~2~:" :' }:~i~W"?:,:; ., R k .. ",.'0 'r. '>, ,:~' " . emar s._). .~. ..."! ~ .j.;,_' ..... .. .~~?:~~.~ ~X~~.~.~; . ~r . ~?: ~,<: . ",,' . ::'""":,,;~~ 'DIFFERENTIAL ',""NO:','1'''V<' ,PRES .::. RELIEFi' '., ..,.~ OJ. .'. t.'... .-..,'" ,','" -, VALVE.....'..,':.- ..- ". ': '. . P.S.I.'" ,,' Differential. '.' .....t -,! '. ~ ..Opened' at"';':'" . " lbs. " Differenti a 1,; ., '. . , .'.- "1. ., . . \ ..... '_'. :t.:...'..;.....: P:S.I.: '" ',::, ':',. . Opened at ';',<-: ,Differential' ':.,', ,. ':' lbs;r::-: <:: ,...,' .':.~ ,~': : DiffefeTlJ i aJ ' .. ' .'" ,..1,.__..",. ...., : . .. J .. ; :~'.' .::.:::'.';~~. ~':> ,*..)~~. Rel ief port . has approved 'ai r,-gap:':.,:'':' ." '. '..; .,: ,..->~ (:~Yes',D"':: s;.-" 0< ~:.:'i' ,'.. No '.' .' ^ '.;. " '.:-;.' . -' , " -, ' ~,~/7~. ..../~~::.,:.:.(;::. :'. r ;": . ~ ': > . ,,' :~.<~ . , . . '.' . .' , "'". >, . '. :", . ";r THE ABOVE TEST HAS BEEN COMPLETED , ' ~. .. ':. ... . ". ' .,' , ~ ., " FIRM NAME: ADDRESS' . ,,)(;(, S" 1\' I SIGNATURE OF DEVI~E OHN~R O~ R~PR~SENTAT!V~' '.,V (,,') " , .. '.-." ~, .' . ."- ~ i~ . J . ";. < :'CHECK NO.' 2' ",,'( NO.2' ,Leaked:'O.,,; ,,:: ..." :.:. ;;. "' ".c~osed,~,~ ..llght "', ,;, . ~" .'. . . v '. (i";. \;'''; r :,. ..' riClose(:D .'... Ii ht" ,': ~;~.~:'I ~.: ',.) ~ ~ .~/:.~: .~.~. " ..,1. .-. 7.: _ .".... . ....: ~. .\.,' ~ t~:. \: ".:'~~ ~ ,": oj,.'; '; :.,J;,,::;~::':: '.'; ,~ ....... h .' .' :.). l :' ':. :,~'.' ~.I.. '. ,:,,,' ~J..,' '. .-' ..:. .t.~~~:'. "<\;'::--: '~". "; . ~ .'. l'~ . . '" " .. ..~. .~. ~ePill,re~ ,by:' pate: --,.;t',. , ' :""" ~ ~{." : ~ P.S.1. Differential . . . ;';~J /.Js I P.S.1. ' .. Di,fferel)t,i a 1 .-:-.' . '.!:. ~ ,'.... .;. . ". ~ .' '-"0 .'. ;" . ". -'. , '.~ ~f',. '. . '.'. r., .. .... . ,., <, PRESSURE TYPE VACUVH BREAKERS Air Inlet Check Valve Opened at Ga,uge Readi ng Held at Gauge Reading D1 d not open 0 Opened at Leaked 0 ... Held at " . Valve 12" above hjghest head . Ye~ [] ; No P . Double Detel=tor ~hec~ v~lve we~er ije~djnQ prp T~5t ' After Tes~ After f1~shl"~ Teste~ ~Yl '7:3.-, J(i;< IJ' ~s.,~ / ~.I 7 Certj fjc~tlOJ!" ~~.: Date' ';' /, .7 ~ 31-.43062 AevlMd 2.85 . .' -- ~J~ _/ I ' NEW ur EXISTING [l;,I~X/ "BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT ~ ,'I :.~ . ,.. ()/ j" i?c: IJ SERIAL NO.:S 7-4/,7 .We have made the following test, as.required by the Oregon Administrative Rules 333-61-070 ~ . . . '. -" . . - ' " '-'.", '. I,-~'.:" " . : ADDRESS OF DEVICE: I? hS .:5t";t7"F/ '/I ' ' <),?/i) , ; LOCATION OF DEVICE ON PROPERTY: ...ffA<:..'7 - Stile /1)' /1J.. I;~, C0,/#';2 TYPE OF:DEVICE: /)/!&1(.>tci'Y-/c:t'K SIZ~: DEVIC~ 'SERVES OR ISOLATEt: !:A.","N /AIA''!-:' .e<;t( ,#/)t V " -. ., DIFFERENTIAL PRESSURE TYPE . ,', CHECK NO. 1 ..',.., 'NO. .1 PRES. RELIEF CHECK NO. 2 NO. 2 VACUUM BREAKERS VALVE .. Air Inlat Chack VaJva .. ,'. , ' . 0, Leaked' 0 Test . , ' Lea ked P .5. I." , Opened at P.S. I. Opened at Held at Differential . j". .. Dlfferent ia 1 Before' Closed 'rsY lbs. ' C] osed GY' - Repai r~' ,Tight Differential Tight ," \0 oIL/.7 /'$ I Gauge Readi ng Gauge Reading ~ ' . . . ~ ' ;.. ',' ,~ :-.'! ~ -', , ' , , -", 'J Test'.-, .: After ,.., Repai rs:. '. . . ~ Closed 0 Tight P.S.1. Djfferjlntial Closed .0 Tight P.S.1. , Differential ~; Opened at . ", lbs. Qifferential " . ~ - .' -,.~ . 1-- :.. ',., Relief port has approved air-gap:" ;~ .,":,' " . -.' New Mater;ial s -,,;, .. . , . and Yes 0 . No 0 . ,," Repa i r~,'. Made,. . . '. ~"; :', .' " , ,. , , .. " ;..:. ". Remarks:, ~..~.. :":, , ... ~,. ..." , " . . ,.': .\" ~ .' " , , ", . J. Repaired by: Date: .~ .t... ' i THE ABOVE TEST HAS BEEN COMPLETED FIRM NAM!" , " I.. \ 'J -^ ADDRESS' I ') (pI., ,f\ 51 (I) SIGNATURE OF DEVICE OW~ER OR REPRESENTATIVE: Di d not open 0 Opened at Lea ked 0 Held at Valve 12" above highest head Yes 0 No 0 Doub 1 e Detector Check valve meter Reading Pre Test After Test After Flushing Tested by: -;73..." /l'<',,/7"o.',0 Certificil,tiop/. ~9..:: " ',',7 Da te : '.. /, : 7' " ~37-"3052Aevised2.85