HomeMy WebLinkAboutPermit Plumbing 1980-3-2
BACKFLOH PREVENTION DEVICE TEST AND M!\INTENANCE REPORT
TO WATER PURVEYOR
JgJ
~7(
EWEB - RAINBOW WATER DISTRICT - SUB -MEDFORD WATER COMMISSION
ATTENTION CROSS CONNECTION CONTROL SECTION
We have made the follow1ng test, as requ1red by the Oregon Adm1nlstratlve Rules 333-42-230
TYPE OF DEVICE /~c-/;~ ",- .><0.:;>--'/
SIZE' '.-/~ /
SEPIALNO. F 7/',:"'.j
/
LOCATION OF DEVICE ON PRfJPERTY ~r:j; E~dl.;'c;:mL-
CHECK NO 1 NO 1
Test Leakec1 ( ) PSI
Before Closed _01 fferent1 al
Repa1 rs T1ght ( ,)/' --';' ( )
Test Closed PSI
After T1ght ( ) 01 fferent1 a 1
RepaT rs
Ne,:
,aten a 1 s
CCl/?/'/n:,J
-----'
,
and
Repa 1 rs
.Made
DIFFERn1TIAL
PRES RELI E F
VALVE
Opened at
lbs
01 fferentl a 1
Opened at
lbs
Dlfferent1al
Rellef port
has approved
al r-qap
Yes' .
No
THE ABOVE TEST HAS BEEN rOMPLETED
FI RM NAME f:;~ ~1 h-u.-v ct-- -/rn",-f~-:".f}
~ '~_ _ __ .,-- - -1 -. I ~ .
ADDRESS I~.. 5 L-......-1~.....Z;=:..v.:;.r"\~1-t~... / _ 1 J)'......;-...... ...~.-< L.fr
l
/
, -- "...
->:;',,!- ,
~ ~ j:;:r-
r~~' -
SIGNATURE OF DEVICE OWNER OR REPRESENTATIVE
/
/?1
PRESSURE TYPE
VACUUM BREAKERS
CHECK NO 2 NO 2 A1r Inlet Check Valve
Leaked ( ) PSI Opened ( ) Leaked ( )
Closed Dlfferent1al Old Not Closed
Tlght (1')- - .---"'/' r./ Open ( ) Tlght ( )
PSI
Closed 01 fferent 1 a 1 Closed
T1ght ,( ) Opened ( ) Tlght ( )
Co )1 /. /V>>tV
Repa1red By
Date
Jested l:5y --; _/> "---::-~f-l"""'-c..-__
Certl f1 catl on No C-297
Date /-' /1/
/.
~ /1 /'#
./".1 ./~ ;r// /'" ~
TESTED ByC"'-;l.-C 6r'>---,. ~:;~.$'::/..-6-1
TED KRAUSS
BACKFLOW TESTING REPAIR SERVICE
J Of3
/2
--
~o