HomeMy WebLinkAboutPermit Backflow Test 1982-2-23
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BACKFLOW PREVENTION DEVICE TEST REPORT
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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:
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",(~
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
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TESTERS SIGNATURE
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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
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GAUGE it
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CERT "
BY:
(REPRESENTATIVE OR FIRM)
I CERTIFY THE ABOVE TEST HAS BEEN PERFORMED
WATER SYSTEMS COPY