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Permit Backflow Test 2008-2-7 (2)
';.':.~., 0;: ..; ',"/<. '. " '.' . PNWS~AWW A >, ~.. '~., , .I7-7545._:" . ,..~ . ,~ . I - .' :1!I-tJ E~ ' . . 'T" '. DEXISTING BACKFLOW ASSEMBLY TEST REPORT .0 REMOVED:,." /../J. . " / ;"'.' " 0 REPL'ACEMENT .11~/ <'-.':/f ~/I t?d'!? PHONE: :i PROPERTY OWNER: ' MAILING ;,,, '. ADDRESS: :;! <n ? /, ,:~ T~ -" /" a- '~""ISTA ~ , y~;......". ~- ;~~~~~~~2.?9'-' ,4-f~r:r-:.'~' , '.', ,'''" ... ',STREET ",q~,!.B:A. 0 DU.A, 9 R.P.D.A 0 D,C.D.A tta'P: V.B.A. ',,:SIZE: T' II,., I l MAKE: /A.I/1 /< In' ( .' 'W;~TE'R"',-' , 'i!:"" /.; ..-cQSERIAL " 'R~y'OR:; '. ,;;; {'/f b ' " NUMBJ::R: ~~\~:f-h'({(f,gvg~;'/:/d..r -5 (oI-e h a V re ::~~~~::~~l~~~?(:~,..~~~ ":". '.'~.' __:' ,. CITY C)p- ZIPr ~-:}7/'7{J" t~"'_ ~ ,';' . o S.V,B,A, 0 A.V.B.' 0 AIR GAP MODEL: 7 7-P It trlo/l67<7 ~... '.. REDUCEDPRESSUREASSEMBLY P.V.B,K / S.V,B.A :;::;;>::. MI C,HECK ' Jl'~D~~i;~lt'efi1l~: AIR, CHECK . ".L:,:: PRES~DROP (A)I CHEC~ #1 INLET ;=;:~~~~~~~:bv~~~E .' (B)ITIGHT,:.:g ''J'' 7:E~A~ " "K. , .' ,MIN 2 PSI!:! , " ,LEJ\.KED'mh-~~g;:.~ .'Z.l;~.' RE~ULTS BUFFER 1 !~,,' <~ ., - . f' . 'A, B = r ~., I CHEc~;'ti2..',;~.,;;"., PSID, " .MIN 3,PS.,1-. _ 'L,'~"', . '~: ',' . i<' ~''''':DID NOT 'RELlEF"VALVE': ITIGHT{_.;$";~~D"" OPEN 0 _ PASS 0 F,AIL, 0 ILEAKEqO,,? PRESS DROP , Z'i/?i" .:.". ... ~:..-- . " - '.7' ., P"SID INITIAL TEST P ASSED~....: FAILED",O " ...}I ' DATE: _:.",,~.'~~ :,:,,;~ 2./ 7 /Y ," COMMENTs . REPAIRS , AND/OR' PARTS :f'), F AILED SYSTEM o .....p,SI' ~ ~ \.' ~i .' REDUCED PR.ESSURE ASSEMBLY #1 CHECK ' PRESS DROP .- .<A) . RELIEF I OPENED' AT. PRESS DROP OPENED (II) TIGHT 0"'- PSI6 I \ BUFFER ~'t= ..' ICHECk #2'~ :~ A,B-' I PASSED ....,... TIGHT DpSID,~ 'PSID ,. ~SID '.. , IN COMPLETING AND..SUBMrmNG TIllS TEST Rl::p'oRT.,TIlE TESTER CERTIFIES TIlAT TIlE .,' . ASSEMBLY HAS BEEN:'TESTED' AND MAIJoITAINED:IN ACCORDANCE wrrn ALL APPLICABLE - . '- RULES AND REGULATIONS OF TIlE WATER'SYSTEM. AND STATE REGULATIONS, -'GA~GE CA~~B. RATI~~DATE.B. Z"/. '7 DETE:~?~ ~TER' READING. I" ~hf.L:---:-'~~ ~ ..."", , TESTER'SIGNAlURE.; '. ./ . ,/ ... " Willi;llm W -Kiilg.qIA~ II .. ; '"",n:,srE~S NAME PRINTED ;~O Box.11452 Eug', OR 97401 , .~~~RSADDRESSi . "'" \iV"l~1 rivw 3~ICliOels: .TEST -, A,ITER REPAIRS P,V.B.A./S, v,sA AFTER REPAIRS DATE;: . ' / ':'/ '1S~t 03061033, .. 729-5575 GAUGE . PHqNE, M . , C.oMP~YNAME ;. REPORT, RE!;:EIVED BY,'.. I- ... ,~.~ r"1:~E~N'O~S~O:\~:,,;,: ',YELLOW,TcsterCopy :. '::,.' J.. __,.' .' )=:.. l;{.~..'.~.--" ,~. ....";j , :. ':' (REPRESEl'ITATIVE OF, OWNER) ......,-. ~HITE'W~~ S)'5Ic:mCopy i. .PINK ' Customer ~1iPy