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HomeMy WebLinkAboutPermit Field Test & Inspection Report 1986-5-20 BACKFL9~ PREV_E~T~ON DEVJCE TE~:r.~~D MAINTENANCE REPORT TO: ~(;h~ tlaq~4/lZziv~~~ fJCL-') /07~ /1 -='"-.-'~ We have made the following test, as required by the Oregon Administrative Rules 333-61-070 ADDRESSOFDEVIC~ ? r?S c?/'/mY/r _ .NEW ~STING LOCATION OF DEVICE ON PROPERTY: /f/~ Cc/l/;~" 0 /'On.-/r.rnup R:./ p.h~...w./~_ ",,-.4?P'7':lv.r.0//.'p,-:d-/_- TYPE OF DEVICE';':::-P.{l/? _,(7J-.f / /'/Y SliE~~;> SERIA~ NO,' //_5'5,Y,t '... ' DEVICE SERVES OR ISOLATES /~ T/f {?l'f" -hi--.... .5/---,,,k'/'p,/ 5'y'--I-/,o"" CHECK NO.1 DIFFERENTIAL PRES. RELIEF VALVE NO.1 Test Before Repairs ---- (~ P,S.1. Differential ) Opened at Ibs. Differential Leaked Closed Tight ( Test After' Repairs Closed /"" Tight ( ~r ~ #/c~ M-.~ P,S,I. Djfferential ~r) Opened at Ibs. Differential New Materials Relief port has approved air-gap: Yes:_ No:,_ and Repairs Made --- Remarks THE ABOVE TEST HAS BEEN COMPLETED, / FI~M NAME: 5 ~<t4 /01V~J<I?O/J/7,;tJ~<<-' ADDRESS: ~ cfFJ cJL;//lJ'pW :>PY//':c;';;PfJ~ SIG~U}lE OF DE~~S.E.o~~~R/~R REPRESENTATIVE: /,~(//(<"......I.,..>-. ~Z;l,.. /' !-.J . CHEC~NO. 2 Leaked Closed Tight ( (---) Closed ,,,./ Tight ( -I . ~ ;/2c;t;i Repaired By: Date NO.2 PRESSURE TYPE VACUUM BREAKERS Air Inlet Check Valve P,S.1. Differential Opened ( Did Not Open ( ) Leaked Closed Tight ( P,S,1. ~feBlntial Opened . Closed Tight ( Valve 12" above highest head Yes_ No_ Double Detector Check valve meter . Reading Pre Test COacu) j After Test - After FlushingOOOa>2- IYe72:e .!?pu.<Z.I::>/>7c, ~~ J/A;;-",/u/ / Tested By: J~/7f:/"~ Certification No.:C022? Date: 0--:~JO -/.9// " BACKFLO~ PRE~_NTIO~ D~VICE _TE~rAN~ MAINTENANCE REPORT TO: ~(~ (;;:J~- Vtdk-~~-kJ ;J~ . Zc.- ( 0 '1 .3 .s -:l- o-CJ We have made the following test, as required by the Oregon Administrative Rules 333-61-070 . .' I 0 ~ (, _, ADDRESS OF DEVICf 0-/ eFt' ~- r2h'''H-::'''; NEy.'.t:==EXISTING _ . / _'. LOCATION OF DEVICE ON PROPERTY: / c::v ~CakP:(./ 'T~ -- .Z;;~,-7 -17 tl17.k, fhtp ~ . V" TYPE OF DEVICf' tt./t2':z'~ C?~c;> /P P / SIZE:.LY;V SERIAL NO' //"7 9~P- / - DEVICE SERVES OR ISOLATE~ ~.~% ... .".. do' CHECK NO.1 DIFFERENTIAL PRES. RELIEF VALVE NO.1 Test Leaked ( ) P.S.1. ~APed at Before Repairs \ Closed / Dif7?ntial , " Ibs. Tight ( Differential Test A Iter Closed P.S.1. Opened at Repairs Tight ( Differential Ibs. Differential New Materials Relief port has approved air-gap: ~. Yes:~ No:._ and Repairs Made -' Remarks THE ABOVE TEST HAS BEEN COMPLETED - <)"" / ',(/.-;-n / '7.~ ~ /,l FIRM NAME: C7'-C~/!/f.J/~_ ///.::z.-/'~.J1t;/- // 17"/~ ADDRESS: ~ ,?fI C~0-:.U<-.)--ShF-~'f'-~~ SIGNATURE OF DEVICE OWNER OR REPRESENTA:rIVE: I I J//J/'[, ,-/,'/':c..{/I~,'""J.~./ c.--,'" ~ ,..#.-J . I CHECK NO.2 PRESSURE TYPE VACUUM BREAKERS '. NO.2 Air Inlet Check Valve Leaked ( ) Closed T ig h t (....,..-- P.S.1. Diffe~l}/ltial " ;5'![ Opened ( Did Not Open ( ) Leaked Closed Tight ( Closed Tight ( . P.S.1. Differential Opened Closed Tight ( Valve 12" above highest head Yes_ No_ Double Detector Check valve meter j .i ! , ! I , " Reading Pre Test Alter Test Alter Flushing Repaired By: Date ..--;: .~<h:::: "- Tested By: f'&f/~P;~ Certification No.:[' 1'--::;;9'7 Date: .5- -;.Jo ;/oc-::?.c;' . . " ~ -- ..... ---- BACKFLOW PREVENTION DEVICE TEST AND MAINTENANCE REPORT / TO:~W;;PUAV /hr:/~~~k~~ .f\)eJY t(,_~~ " f~" f I) I ( ~ ..::-~ -:t.. .. We have made the following test, as required by the Oregon Administrative Rules 333-61 -070 ADDRESS OF DEVICF .-:;:' ..P::r--S /2~~ "';. . NEW ~ISTING_ LOCATION OF DEVICE ON PROPERTY: ~ '~F l'7AJ-1~ C/.hz;~---1!7d$_~~. I rU";/UA /~.""'~ TYPE OF DEVICF';:::;'~ Po C ~/ _"iJ /J,~ / SIZE: t:: -'l , SERIAL NO.r.3 <:c/J: / DEVICE SERVES OR ISOLATE~ ,2;1/7 RP'" -h;:''''' "52'~,.r/-",~ _ S:YJ-I~ /DI(P Air Inlet Check Valve CHECK NO.1 NO.1 DIFFERENTIAL PRES. RELIEF CHECK NO.2 VALVE NO.2 PRESSURE TYPE VACUUM BREAKERS Test Before Repairs Leaked () P.S.1. Closed ~ - DilfeW'ntial Tight ~- ..7-' Opened at Ibs. Differential Leaked () P.S.1. '-;" Closed ___ - Di@e.nl1al Tight (v} Opened ( DidNol Open ( ) Leaked Closed Tight ( ) Test Alter Repairs Closed Tight ( P.S.1. Differential Opened at Ibs. Differential Closed Tight. ( P.S.1. Differential Opened Closed Tight ( Valve 12" above highest head Yes_ No_ New Materials Relief port has approved air-gap: Yes: No: '.. Double Detector Check valve meter Reading Pre Test Alter Test Alter Flushing . and Repairs Made Remarks Repaired By: Date T ested BY:ft'.,{~~--::::-.?--- Certification No.: C c79? Date:,.:r oJ ("J -/'0-/-/ /Acov e "'--<2> ~ /'.;l....l, -S 0 ( '-( ~0(uC(337-G/CJ THE ABOVE TEST HAS, BEEN COMPL~TED / . FIRM NAME: ~~4- ~r;:7...bktf/v 0tl~~ --? (> ~ /.' ~ . -!!, .....-/":4~ /7 ADDRESS: rL d-,r..J c_/-0n)-.:UC-----r5jb)??.Ji./-cL-~ SIGN~~5PF DEVIC7 9~NER ?R,'RE~RESENTATlVE: /1' a'" -. ) ...:: .<f...-.>:, .'c '-J I _ . . .,