HomeMy WebLinkAboutBP17-089 I Ya7K lSTATE:ICwa SARTMJI70FItakTH
9. Report on Test and Maintenance
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zap;,Ny122?i of Backflow Prevention Device
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Please use aseparate form for oath device. '.rule
I �Ie'dial too-CArnpiate amen:fa T.
Annual lost-Comploto Par.A only
PuSD:Water suCDt) I Aco's�r No. I Cco.r. I e:-1 Lit
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Device I Atamfa]u er Typo �RPZ Model Size(In ImIM) Sertad Number
Information DGv t; C)-.L-5 Zvi Cpt•}}-•}-O
Chet vahM Nm 1 CIS Valve No.2 I DlRmenBal Prwtuaa Regd Line Prossure wl
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Test La3kvc rH� ;..eked 0 Oponad ajZ (_psld Date
hetoro ClcsedCght I,y� gasoa ftht ®-. I
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Pressure Crop acres&Urrs checit valve M D v
14 or
Describe RupakW by
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1117tC1'tals
used / ( n Uc d
An(/^ Datempalred:
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Final tost Closed tight _ Gescd Ught penoa sid Os
Pro=wra drop acro:3 rant IN D Y
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1M w mel Number Meter Raadlrg Typa of S cne)
9 Domestic 9 R 9 Other
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Cordfrcebarc Thh device Lam-meets. 0 Coos NOT moot,the nequuemonu of an acceptable mnbinmenl de+Ace at tre teas of tateq 1
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raw)ang dale to ae mm» 3. 31 r 20 Z f
Few LJQ�}( 6}O nifi _T +c ny Q S O o'yl c•��^' F�Oif1SM Dr.
Ptcps.'ty tribes tar c fflam/a-o7.nft ow"cation%at Wt xas Puff -. Q
slut.._.._ 1L t'ale �.a...j? Ttl.l1b•e
Gmtlfientbn Uwl(n--ftib tlon h(n namrdance with the approved Plans. (To.e mmok=4 ty er dn4m mplrser w arCCNd d.am
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I fro"camv Curl u"hRaeatii b In eacwdaem weh are approved pmm
Nam. RussellPIIIUtX1 acr psyp / 0 SI I !8 N"SCt•Log 4
Llcertso Number 78721-1 _ •6040 -m d y PdPN
11.pmwn.ng Prime 50imans, ri rT Da acnbo m nor wata.n•uon Chong..
Address 140 Princeton Drive
uy, Shelton I V.0 27p 06 r
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