11963 SW PACIFIC HIGHWAY-1 ADDRESS:
4� Qac l '
i:\records\rnicrofIm\targets\building.doc
�p 'f
�3
206911
BACKFLOW PREVENTION DEVICE TEST RIEPORT OREPLACEMENT
i
I
FIRM
NAME ----
DEVICE -- /�-
ADOR � .f--1�= y�
ES f
STREET
6: 64
CITY ZIP
DEICE • DEVMAKE ��J61CtSViMIUOCL:TI�J�LI �1�31 �b.Cl 1lfl/I
WATER SYSTEM NUMBERDEVICE
yi I aM1�l 1 1 1 1 1 1
LOCATION
I REDUCED PRESSURE DEVICE PRESSURE VACUUM INITIAL TEST
DOUBLE CHECK VALVE CHECI' N I BREAKER PASSED 6"/
i CHECK •11 CHECK •2 AIR INLET CHECK FAILED d❑0111 1101
Q�J
INInnI TIGHT TIGHT RELIEFOPE 0AT
OPENED AT PRESS DROP DATE/J
TTsI !�•�rm 1_)•!_Inc L_1J•L j
LEAKED ❑ LEAKED ❑ RELIEF VALVE
PnESI DROP PASSED DID NOT LEAKED
FAILED ❑ OPEN ❑ ❑
to
III PAIR',
A,
,,)/)R
PARTS
•T PRESS DROP AFTER REPAIR
nITI;t I 1 I•I lrw-- OPENED AT PRESSDROP DATE I
T[R EIGHT 1-3 TIGHT ❑ — '
nrrnn+ RELIEF OPEN
I•; !no L 1 1•I I►w
DETECTOR MATER READING
IN COMPLETING AND SUBMITTING THIS TEST REPORT, THE -:STER CERTIFIES THAT THE
DEVICE HAS BEEN TESTED AND MAINTAINED IN ACCORDAI ICE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM OWNER AND THE STATE OF OREGON
ow
-.. --�
� AGo% —. Q�
cSfE iS1ZNATIJRE G��11GE N CERT
TUALATIN VALLEY FIRE & RESCUE
AND
BEAVERTON FIRE_DEPARTMENT
FIRE MARSHALS OFFICE:
(503) 526-2469 POSTED:
9Fa Eg /
OCCUPANT PyN +.-
CONTRACTOR —BLDG. PERMIT 0
PROJECT r' I PLAN REVIEW dk
LOCATION
JURISDICTION: 1= Be. 2= Du. 3= K.C. 4= Ti. 5= Tu. 6= Sh, 7= Wi.. 8= CC 9= WC 0= MC
COVER FINAL SPECIAL FOLLOW-UPJREINSPECTION ATTEMPTED FINAL,
❑ Framing ❑ Separation Walls ❑ Sprinkler System
❑ ;haft ❑ Fire Dampers (Overhead;Underground)
❑ Alarm System ❑ 'food' Extng Systems ❑ Conference
❑ Spray Booth ❑ Ceiling Cover ❑ Other
ul
dfu5u - 1 1�0vP-�� _
i
Date: ;.� Inspector: �:''�� 0
IN � TUALATIN VALLEY FIRE & RESCUE
AND
BEAVERTON FIRE DEPARTMENT
1 — FIRE MARSHALS OFFICE —
(503) 526-2469 POSTED:
OCCUPANT.
CONTRACTOR __ _ BLDG. PERMIT 0_____
PROJECT NAME PLAN REVIEW (k
LOCATION
JURISDICTION: 1= Be. 2= Du, 3= K.C. 4= Ti, 5= Tu, F= Sh. 7= Wi, 8= CC 9= WC 0= PIC
COVER FINAL SPECIAL FOLLOW-UP/REINSPECTION ATTEMPTED FINAL
1-1 Framing ❑ Separation Walls � Sprinkler System
El Shaft El Fire Dampers (Overhead/Underground)
❑ Alarm System � Hood Extug Systems � Conference
El Spray Booth Ceiling Cover Other -_
17
t
i
Dates - -_� — Inspector. '� �- 0