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BP17-083
ATE cr4r rc-F:rr at KSTc Vls!- upoty P,ot FNEa HEALTH Report on Test and Maintenance 3urn.0 at Publ:c Vla:e•Supply PhotcC.gn Enpne State Pima-Coming Tower Room t 7 tp •'f_arr1,NY ImT of Sackflow Prevention Device )rr I' t' Please use a separate form =or Ih5 year � _for each device. 1 Q tnFal Cast-Comptotc ontiro form 0 Ar:rual xst-Compralo PD.-(A only iPsmtcc wntar susir I C rrr 3tac¢ I Loh I Fac1.q Name r)t IT: t ^� 7 Iqry "—, i1ra,K __•ca: U0, Ilp [),-Ace 4tamrtadaer Type =RPZ Model S-' -,}^inches) Serial Number W fin. � OCV �t `JU k� l d, I Gay�s� Check Vahm No.1 Check Valve No.2 Oltfumnital Promuru RLlaf Line Prwmrw nsl i Vrdvo �'� Tort Wafted tnaked � Opened at�+-.Psld Data before Closed tight EE Closed tpht © 1 1 Q S repots Pressure drop acre s f)rsi cloak•ralvu Al 0 Y psld Omalbo Roam( d Cy Capons and Namu rnafarfals used LIC V f��'A Ill' Oalo top:irud: i m1� 0 M 0 Y Final UW Closed U ht D�r g Closed Ught Opened at psld ! 0 : r Pressure drop across first Al 0 Y chock valve g APSICI Plater Meter Number Meter Reading Typo of Ser+ice:r{cst� ) 9 ComesUc 19 F•rra•F9 other Remarks(Desert*dteaondoc bypasses,o Xtm boron.she davleo,m ocsho 5.:. n the de—amr pow or mty.misauq ar insd.0u.re snaM at=) Certification:This cercc a rici:Z. ❑ dour NOT moot,Ule requirements of an acoepta-b)e wnI phial da'vice at the time of tasting i t httrotry wady alp fartrg.^,77g dale to bo correct.ri .• S. Px Nane Caru.'G.• mt� --` SIGUM w Expkriakoi D-W Pnat"own r q kar+c agan;)conlrication that tout was P,irramod. U L �Q C •�PrJR ttarn: yT Ja s h;jr TNeph one Certification that Irtstnlfatlon Is In accordance with the approved plans. `(To ea complprca ay use de%wn onquecr ar arcridw w watt, p v,Pplm.) 1 htrrhy certi/y Mal this tristdlatlon Is In arcordun LrMr�a Name P�_ ;�z/ /'�kdCr I Dab bcense Number U 7,/__f pnlp'po •*:ri,(, m d y Rept—on Una P'2-4.C ;�J;y.i rJ:.s• 1-!�{r i'~ :��r ecrneo minor�n,Id lotion dhangae nedmzcy�!/ ~�^ Crry SIGnaturo r. .xra nee mn'7� ram,y,o uw cesvina:c:resin�r,�rtrhem reartcrusn one a>r eaGy a t-a ra sr w:7a�r:• ear Ana his::q de..cn. _rcrr DoW laillarsi)