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 _
. .
.,