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HomeMy WebLinkAboutPermit Backflow Test 1982-2-23 l' ()/YI1).;f~ . WJ..1~"" g I~ 6$1,.-25J>. ~ )U~~2328 >f37 <-:;:.>/ ,/ BACKFLOW PREVENTION DEVICE TEST REPORT ub:P,,J16O, , ,O~), ~ 59, ~AJ, , L ' , , , '----1-' , , , 1 , , , I . STREET , I ,.:5J'1El,fl , , I , , , , ,tJ}tj7'ZL, , , , I V . CITY ZIP ,/, ~ , ~~~ ,J(-fKtLJ MODEL' q~.$' ~, SERIAL )71/')")<./ NUMBER I .,.-;" L/ L J7' PRESSURE VACUUM INITIAL TEST BREAKER PASSED Er AIR INLET CHECK I FAilED 0 OPENED AT PRESS OROP ,I DATE:~/~~/L16 LLJ.UPOO LLj.UPSIl i 1"1 PRESS OROP o LU.U... I REUEF OPEN L.LJ. UPSIl DETECTOR METER READING IN COMPLETING AND SUBMITTING ll-US TEST REPORT, THE TESTER CEA11FIES THAT THE DEVICE HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH All APPUCABLE RULES AND REGULATIONS OF THE WATER SYSTEM OWNER AND THE STATE OF OREGON. FIRM NAME: DEVICE ADDRESS: DEVICE SIZE: DEVICE LOCATION: $cpt.-I< ",(~ I REDUCED PRESSURE DEVICE I DOUBLE CHECK VALVE I CHECK #1 CHECK #2 INITlAL I TIGHT 0 TIGHT 0 TEST i lEAKED 0 LEAKE" 0 I CHECK #1 I PRESS OROP ~.&.... REL OPVl~D AT L' .01 PSI) REUEF VALVE PASSED CY FAILEO 0 I i ~PAIRS I I ~~~~ TEST AFTER TIGHT REPAIR o llGHT ~~ TESTERS SIGNATURE __ .1l(}?.CD I l.rr I I I I I , I , DID NOT OPEN 0 LEAKED OPENED AT ~ II AFTER REPAIR ' PRESSOROP !OATE:LU/LU/LU LLJ.U pSC LLJ.UPSIl i /~5 GAUGE it c:: ;.$35" CERT " BY: (REPRESENTATIVE OR FIRM) I CERTIFY THE ABOVE TEST HAS BEEN PERFORMED WATER SYSTEMS COPY