HomeMy WebLinkAboutPermit Plumbing 1990-9-7
I
~
,PJ:p
llf823
,
\
~EW
BACK FLOW PREVENTION DEVICE TEST REPORT 0 REPLACEMENT
DEVlCE
ADDRESS
(!;; /l [e.Y 1/ fi- -5
J~;.5..s- G/lk'--0v"',,-y
,ST5fET I
':;~rl""""'Z(:','elc:f QrC7O-J
CITY ZIP
FIRM
NA.ME:
~,~~'CE LLJol ~S1~~~E l{v,(97f~
WATER SYSTEM //JI',v00-<J
DEVICE 0u,'-'..-r IZc,o-^--
LOCATION I'
REDUCED PRESSURE DEVICE PRESSURE VACUUM
DDUBLE CHECK VALVE I CHECK" BREAKER
CHECK' , CHECK' 2 I , AIR INLET CHECK
~ I OPENED AT PRESS DROP
INITIAL TIGHT [JjI TIGHT ElIEF OPeNEOAT I
TEST LU-UPSMl LL'.~pslO U-.J-U"510
RELIEF VALVE
LEAKED 0
PASSED 0, 010 NOT
FAI LED 0 I OPEN 0
I I MODEL' ?4? T,
SERIAL <:: U C r'I J
NUMBER I ([) 17-t-..J1 I..I-I...J.......\I
'-.-1-1
I
,I FAILED 0
DATEl.6 ~ m
INITIAL TEST
PASSED .
LEAKED 0
PRESS DROP
LJ J.l~JpSIO
LEAKE DO II
REPAIRS
ANO/Ofl
PARTS
TIGHT
o
TIGHT 0
I ' , PRESS DROP
Ll.J. LJPSlO
I RELIEF OPEN I
LU-UPSlO II
AFTER REPAIR
TEST
AFTER
REPAIR
OPENED AT
PRESS DROP
DATE u.J'u.J/u.J
l_J.-.J.UpSIlJ
Ll.J . LJ PSlll
DETECTOR METER READING
IN COWPLETING AND SUBMITTING THIS TEST REPORT. THE TESTER CERTIFIES THAT THE
DEVICE HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM OW'NER AND THE STATE OF OREGON
~t~ c:L..-=4;J
(j TESTERS SIGNATURE
:~PORT R~ 7~ //CI"-7'1
't,QJ
:R-] V G
GAUGE"
cA,J/
I~ lREPRESENTATIVE DR F1RMI
CUSTOMER COPY
CERT"