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HomeMy WebLinkAboutMiscellaneous Backflow Test 1996-4-24 BACkF!.OW ~R~'VENTION DEVICE TEST AND MAINTENANCE REPORT j I TO: ,(/7, L.( SC<7'! S v3 jVeY 0 r: I () q..;;J ;.~ ~ 6GI'J'rZ ':// ;- ;-v v V ~:t. . <I-~ We have made the following test, as required by the Oregon Administrative Rules 333-61-070 ADDRESS OF DEVICF L/ J", -Z. //:7t..'2:?-u.- , NEW ~ISTING_ ----- .' LOCATION OF DEVICE ON PROPERTY:.6'y /?lv-1:i- J1Jj~//VY7 .s:1i1'<:~,L-- ~ TYPEOFDEV/rl=' 0P.of',.) ,<::-'.""-y',,oj' SIZE; I" SERIALNO,;C 37/79 , ~ DEVICE SERVES OR ISOLATES :;:...~ T//E'-:"J7 . DIFFERENTIAL PRESSURE TYPE . CHECK NO, 1 , NO.1 PRES, RELIEF CHECK NO.2 NlC),2 VACUUM BREAKERS VALVE , /- Airlnlet Check Valve I J , ., I . Leaked ( ) P,S,I. Qpened at Leaked ( ) . P,S,I. I O~~ne'd' Leaked Closed Differential . '" (:, Ibs, Closed Differential Did Not Closed Tight (....)- 7:. ./"J Differential Tight (<-I/o' /' . Open (,.) Tight ( /--. . /", .' Closed P,S,I. Ope)Jed at Closed P,S,I. Opened ( Closed Tight (yY""" Differential ,,', ,Ibs, Tight It-- )-' DifJerential Tight ( /., ./) Differential ~- . &,v Valve 1 2" above highest head - Yes_ No_ '; ::- Relief port Double Detector has approved Check valve meter '. air-g~ Reading Pre Test Yes:_ " . No:._ After Test \ I, After Flushing , Test Before Repairs Test After Repairs New Materials and Repairs Made Remarks ~~ ~/<d<-<...I~~t /Clt"/(2/!-L . .--;----;/ ... ,.- Repaired By; /~?~<Ot--' Date ,) , - /"1 , 04/# -r .- "./ , .., ,/.- /<'-'(/1 . , - Tested By;4k-.~ Certification No,:c_Y7 Date;r/- .7'/'/':''' / " . "f J-.. THE ABOVE TEST HAS BEEN COMPLETED, . FIRM NAME: rr.-os /"1:;- .:' ~0;,,,s ~~<r__>;Y" 705-:;--- ADDRESS: 1/;z.,~,Z, ??/~: 5,/1}-I>;c/':,' LJ) SIGNATURE OF DEVICE OWNER OR REPRESENTATIVE: ~ <' " J I /, //. ." ,/ /.... l...... (/1'IL pow PI 7/;t.. * r--)':-'\ ' --:;-:---:J / )'"-UV~~ -1- '/o' ~'./ ~/ ./L.-e, ' ~ /p..;;......)....'~,~:.... or!-.-;--."" -:"J b/'':;;,;>