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HomeMy WebLinkAboutBP17-070 NEW YORN STRT'c CEPARTRIENT OF HEALTH eareaJcf?ugcYAtar3unfJyPrticcan Report on Test and Maintenance maw Sbta?'dn-Our:cp Tawsrnoar.1�la Ab.ry.NY I?nY of Backflow Prevention Device Please use a separate form for each device. For he yea IM%21 feet-COmplake nrn'm turn Annual ta7-Corrplofo Pail A only PuSl1c N/slat 9uc:fy A000xn N. Gcv.y a!ad Lnl Facility"... 1 �e K ,I nc1 _Cip Locmuonwowfw Or 1 �� tPr f� ooM A-dre>tr '� Rll:z :-.Gr..* rt'f?r+f 66{% I n^ i 3AR: ZIP Device tvi Manufacturer Typr 0 RPZ Arodel Size(In Inches) Serial Number I Irtfmma ( �I I k t k S z DCV q1`J Chock valve No.t Check Vero No.2 Olfferen Uel Prossurn Railef Urm Praaaum Gal valve Cote Tact Lacked Leaked Oponed OtL�psrd berom GIC."m Upnt _Canes Iiam .© m o 5 { mpafr rGsarrro drop across first Check vnNa M D Y pdd Caagtbe Rapaimd by repWm end Namo moEmfatz uaod /^ / Llc d N117� Dale repatrod: �� se rr��--,, Y Raw bw Closed tight Os 11 Clod Lghl 1 \1 Openod at—U- psld Pfamure dmR acraa runt ft M 0 Y Cladkvalvt JA paio wow Meter Nurrbef I Mir"Raading Type of Service:�(check one) 9 Domestic q R 9 Mar Remarks(oex"®a dd wndai oy=aL ouw•3 b fam ft reriw.=_1Lnu benunan mn d, ane p&w �,b�.riwno er V•:eeQwra ahooM.kt) Con"'catktn:TN,dovico moats, F dcoa NOT moat,Iho rcnukements of an eccoptable cantalnment device at trio Ilme of testing p I harry cp+�fy tho Gor%6N data to b.na�oc� vy� Dr 'z Mo{C( 1'�—F,T- .j a `i'a _r ftJ/✓l�''—�. Zi_r31r a OA PAN Marne Cow,-:rl TcSL trn. fiVnAtoc Om �� cwrwnjk±a o nt)eertifikaUon teat tad•r.•aa parfarr..ad. .� `� _ /�„( � `, P-r 1_tL'1�S Cl�' J�i - �t�'� i (C{[fit A Y n frll'O Me Tdophorla CashrnesUon that Inaralration is In aecudaneo with tYe approved plans. fro t»conipteted by dae desire erylecmoructibd W"I" awaOecl 1 Mfcby corlEy that ttda Wtaaotion in ucmrdunca w1Ut r p.Jns Nome Russell Palueci I n ;� ov<te 1 I 0 S I ,: furs 00H Log tr Ucertso Number 78721-1 i�phpr4{8�k` 87 r m d y Rcii wenting erne out ens. L, on5w ;t.m;na•Inetenauen d,3ra�� liter.. 140 Princeton Drive f prf Shelton State GTE �nefur0 S �� ' _ '• � ` r..a a�a r�ays+wcol/uva:a T.le ne 1• eiO aTa�r J.eJAn One dP.rr t]4^a 1.'Lw cyzx. cane w aayJcrn01S gCGY_. r;7tC NnGe:y u:In a: ea� eu^_sate. Ie�.e'aLl ierrl•3ro ma.a DOI� 1017(on') I n ! raks rm et uvlaatrmy a