HomeMy WebLinkAboutBP17-082 "--W YoiK STATE OEPARTI/ENT OF HEALTH
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�lAza- `suhgT �•`�61 Report on Test and Maintenance
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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
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Paran Name Tkf I(*ny -Pie1d L...WnOfoer— SPr n,'� c/o �.
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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
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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���---------^^^
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Ffrialma! Clwad fight Gased bight Operted at�pald �7�I 1-��I O
Preaa.ro nt7t L1 N J
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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
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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
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Nam. RussellPalucci 'sri �j ' �-Q I Onto I II OiS p WM=rLog#
License Number 78721-1
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Rapraaerrting time 0 UIICn S, LL. Oil 9
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Address 140 Princeton Dnve '• w
aty Shelton Stale CTx�t 't ggif i II
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