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HomeMy WebLinkAboutBP17-082 "--W YoiK STATE OEPARTI/ENT OF HEALTH sljruF-0.of �lAza- `suhgT �•`�61 Report on Test and Maintenance E+rpLo Slats Placo-Cmvne irn.or naam t!t A]arry.`lY IVV of Backflow Prevention Device Please uee a separate form for each device. For eta yaw - ln?Ifal fn#-ComP.blo ertfJro form Annual test-Cor-prato Fan•A Only i Puh:r.Wafer S"=:, C" I a1a[t LW I Paran Name Tkf I(*ny -Pie1d L...WnOfoer— SPr n,'� c/o �. _ 1 P -- �a Device I man+tact'+fer Typo 0 RPZ rdodal Size On inch") Serial Number IMOrmat}on ` k t k 0 V Q X` I a t t GU L4 7 check Valve No.i Cheek VANS NO,2 Olrfinentrd Prnsaurr.Renal Una Pmasury wl VLNa Twat Data p�..o L°'1tOe Leaked � Opened al°�-s paid Glowed ughl _gftsed 1iy*-� repair em O df�p aQosa iral Chad*valvo M D Y pald Dascribe Repaired by tepalre and Name nmbartela used ,{/ / A/ ./ Da y�V Odle r�epaired���---------^^^ M 0 Y Ffrialma! Clwad fight Gased bight Operted at�pald �7�I 1-��I O Preaa.ro nt7t L1 N J cr:acKveltropeld Water Metier N"er Meter Rea" Type of Sorree:(dw&one) _19 Dbmlmtic C4 Fire 9 Othor Remark')iDemtto aeboend=twamit,oudota b.rom fro dnkl o -CU n bpt. tee d...n.nd Pdrt d nay,m—oc w umm�a*.Y.oan..re> Gamin aaan:Triv davlco %< moots, n 6000 NOT meet,the requirements at an acceMbie containment device at the Brea Of testing _y 1 hereby Qmfy L'tglcrWng data m be wrote*. a ?'I T t 3o,4 r �, [) L.,a� aDV4- '*1 !! l P}L'PJ,1+n• CorLMd Tmtcr No. °ry ownaro�e rq ope*)t)eorufewtion that tjw was perkrmad: C�111\ r'mr trarsa Title J.^^ateio op ar+ COME caLLon Ih.l Instaltallen to In sommaoc wilh Me approved p7otns. Rem cempktee byU..d..;an.nr wroraid." ocna!v _ aapPae+•1 I tie PI`L �ffiyoeAdyemtu,ta Inamtt.tion Fehr:rrorC.ur �rrpllfie Upprt(1r Nam. RussellPalucci 'sri �j ' �-Q I Onto I II OiS p WM=rLog# License Number 78721-1 ' m d y Rapraaerrting time 0 UIICn S, LL. Oil 9 * t— .tcrkn minor motallaaon chaneeo Address 140 Princeton Dnve '• w aty Shelton Stale CTx�t 't ggif i II S•tytraturo t'.177C Seta and u..s!ce s=y w car. r.d nrsrut a.a.raf.m raprc:a- tie and a:a W'.7:a.v..ats w;;�.r t..in v cat.cf_v Etna cars. t:c�/e«rtr era.-a:r t�7afW�•-.r.+.:e r!e:r d en�a'a:r eu a-:n-a:.rs�-'r n.Ted:r c'r:e-a_c. DOw tOt7(9,st)