HomeMy WebLinkAboutPermit Backflow Test 1987-2-19
BY:
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, .........1. /7 J,-- p:" ' -- (REPRESENTATIVE OR FIRM)
-, IC1RTlFY THE ABOVE TEST HAS BEEN PERFORMED
WATER SYSTEMS COPY /'
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BY:
ftI& ~ ___ (REPRESENTATIVE OR F1RMI
v. .&<tft'tIFY THE ABOVE TEST HAS BEE;N PERFORMED
WATER SYSTEMS COpy
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aTERS SIGNATURE
GAUGE"
(;61'
CERT "
,.4~/
~ ~ A"#-
TESTERS SIGNATURE
0..09
GAUGE: II
A 1'77
CERT II
.1 PRESS DROP
LLJ.UPSIJ
RELIEF OPEN
LU.L.:PSlO
DETECTOR METER READING
IN COMPlETING 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 OWNER AND THE STATE OF OREGON.
REUEF OPEN
LLJ.UPSIl
DETECTOR METER READING
IN COMPLETING AND SUBMITTING THIS TEST REPORT. THE TESTER CERTlFIES THAT THE
DEVICE HAS BEEN TESTED AND MAINTAINED IN ACCORDAUCE WITH ALL APPUCABLE
RULES AND REGULATIONS OF THE WATER SYSTEM OWNER AND THE STATE OF OREGON.
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FHR
:PAlR
TIGHT
o
TIGHT
o
LU.UPOO
OPENED AT
LLJ.UPSIl
PRESS DROP
), '.
,)1 !;;("'.
II AmR REPAIR
OATE:U.J/LU/LU
TEST
AfTER
REPAIR
TIGHT
~TIGHT
.1 PRESS DROP
Er'"LUoU..
LU.UPSIJ
OPENED AT
LU.UPSIJ
PRESS DROP
AFTER REPAIR '.
OATEW.J/1!..t.2J/@[,;:?
'AIRS
)/OR
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REPAIRS
AND/lJl.
PARTS
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rlt..c;/, 0-1...., 7,{ ~ o <<-VtC e
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it.;t f)<5G
LEAKED 0
lEAKEO 0
1I1AL
ESl
TIGHT
REDUCED PRESSURE DEVICE
DOUBLE Cr'ECK VALVE CHECK _
CHECK - CHECK -2
o
TIGHT
o
PRESS DROP
U~.lgl'S(J
RELIEF OPENED AT
~.!6:PSIIJ
RELIEF VALVE
PASSEO;t[
FAILED 0
I-
DID NOT
OPEN 0
~
I
f-HZ-
OPENED AT
LLJ.UPSIO
LEAKED
PRESS DROP
LU.UPSD
DEVICE ~4~ OEVlCE C L
SIZE: 7f 71 I MAKE: or I CI <:II C>'7
DEVICE .6~5'lm""~'v
lOCATION'l,<1t'.51 ~,d<,: cl AL..JU
REDUCED PRESSURE DEVICE
DOUBLE CHECK VALVE CHECK _
CHECK -, CHECK-2
PRESSURE VACUUM
BREAKER
AIR INLET CHECK
INITIAL T{g,
PASSEO )EI
FAILED 0
OATE:&/fu/~
TIGHT
ff'
TIGHT
~
PRESS DROP
LU.UPSD
~EUEF OPENED AT
LLJ.U PSD
REUEF VALVE
PASSED
FAILED
o
o
DID NOT
OPEN 0
INITIAl
nST
LEAKED 0 LEAKEO 0
OPENED AT
LU.UPSIl
LEAKED
PRESS DROP
LU.UPSIJ
PRESSURE VACUUM
BREAKER
AIR INLET CHECK
DATE:
INITIAL TEST
PASSED 8""'"'""
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VICE
CAlION:
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SERIAL
NUMBER
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SERIAL
NUMBER
MODEl'J': {J ,5,"'"
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VICE
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DEVICE
MAKE:
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CITY
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STREET
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STREET
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VICE
IDRESS:
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DEVICE
ADDRESS:
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ME:
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BACKFLOW PREVENTION DEVICE TEST REPORT
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