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HomeMy WebLinkAboutPermit Backflow Test 1987-2-19 BY: x , -;:;>/ . .c:::=::::::-./ -... /}j , .........1. /7 J,-- p:" ' -- (REPRESENTATIVE OR FIRM) -, IC1RTlFY THE ABOVE TEST HAS BEEN PERFORMED WATER SYSTEMS COPY /' ----------- . ----------------_/ BY: ftI& ~ ___ (REPRESENTATIVE OR F1RMI v. .&<tft'tIFY THE ABOVE TEST HAS BEE;N PERFORMED WATER SYSTEMS COpy \ i\~ --\\yj\ \ ~\\ , ('I,........ J 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. l51 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 RfS F!os/rr:o l Cldi~<..t .~ I , , _. I <? IOll"~1J t(:diC~' I,': -/ ,f _ /J I (_ V141...,- c C,"''-JI;-() " I,. , 'J ()V~V REPAIRS AND/lJl. PARTS ~ "d-. rlt..c;/, 0-1...., 7,{ ~ o <<-VtC e ~ Tt..;e rU ov.e'" 74... 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""'"'"" FAllEO ~ Ltu 'l~/l&;? VICE CAlION: I SERIAL NUMBER MOOEl8,Z,s,Y; )<",2,8, \ ,PI, I SERIAL NUMBER MODEl'J': {J ,5,"'" /1, b 9", /,/ . I VICE E: fz... DEVICE MAKE: \..lR.~ CITY r~l~ ICO , ZIP ,R,P .$',w-vA!' 6 , , 1J11Aha/ ,S; /I, , STREET ~~,.,/'I r1118 CITY 7iNti7J-;' z'p ,S, p,(?, ,Su,RJ Ul1;JI' STREET ,1':;,,-, D '}, 7, cj, 7,p, VICE IDRESS: .;:;;? ,z,o, ,,"'f~ 11 DEVICE ADDRESS: ,c:j,:;l, 5 f, M ME: .--- ~f 0 ~ G:),~ I lJp BACKFLOW PREVENTION DEVICE TEST REPORT ( !(<?'e.5e lL, Si\i,t\, -~~ ,I o,~ 9-37" 20167\/ lUeuJ *"CKnoW ""'""0" .,.", .", ...0.. F'RM " 1/ NAME: .,.,. I ~ J; /17 E,4ST ~ t,.~ AI..76J IV , ~ '15206 1;;-3 J1J.ew}:y