HomeMy WebLinkAboutBP17-069 rrcW Yoau STArr DEPARTMENT'DFll`JLLTH
Bureau CIP.trKw+yrS.PO,PrJ.M.. Report on Test and Maintenance
emPlo Slot.P'aza-Cv=r4 Tan:Roan t t i e
Ata'•t'Yt`2'' of Backflow Prevention Device
Please use a separate form for each device. r"cr as fear
I Initial taC-Complete DRUM form
annual IW-Cwrpfato Fall only
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Fadiry Name �P K 1 n 5 ?-(e l O L-boR S Pr;A K(Q{,- P,O6 M
Addm:=
Store: Cap zo
Deuce Mawlacturar Type Rp7 Uadol d Size(in Indies) Serial Number f
Inlormaffon W 1 tk S � OG1l [jDX��Q'( c1 4.r Co 7`/
Chm*Valve No.1 ` Clodr Vat"No.2 Dllka eis ential Prurs Relief UnePressufa eel
f L Vat"
Tact LoyOed Leafed Opened atk—psid Dice
before Cksedtlghl �F-] _CteaeEJid)+t- mL'im DE
repair
n-Tm d:ap aaosa first check tahrD M D Y
paid
Dacron Repair d by
rop*s and Warne
nramtlam
used LAad
Date repalred
m
M D Y
Rltalbeat Cosedlight — Cleaadupht Opened paid
6 L�
PreasurD dro oca_first � U D Y
dtedivatv0, t paid
Water Meter Number Meter Reeding Type of Sarviod:(dtedtone)
9 Domeau: (9"'-41 9 Othe►
Remarks(oexrae oveoe cow bypaam ovdots beta.er&,i;L mrtKcS�u t e reen roe e..;m aria Pdrs ar.rri,rwma er uuQaRaata abD?aa�l
CoMfleanon:This doNtx ® moft, 0 dam NOT meet,the requirements Clan a: ;Uble M-ItainT,arli device at the Ume ef teziry
r I ren�y L`a tamgo.ng data to as aonoct Oa
C. ...n l r,4r 9-T �Qu9 �b ✓� t f�
Cached Teesr fa. $"tloa t +
r avrwry{or I)t7 ScaWn plat teal was perkmwd:
PrrS rr7Ro - 7rJe 7at""M
Cerurluuon that in wialian is In pproved pans. lro a Or c,,n;,s a by s.dn w lee sngkeororardtMW arro
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t herby Cary that th:s frtatadat:an Is in aarw O !ag.
U.M. Russell Palucd ' r�� Date ! 0 S I Fj h1Ys DOH lag 1r
License Number 78721-1 m d y
Repreeendn0 rime Solutfcns, on nn s� �-
Daaurta m,,,e,nctatmti>�w„aoo
Address 140 Prbiceton Drive :y- "7573I A
city Shelton State
Sign2ture � �
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