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177427
❑ NEW
BACKFLOW PREVENTION DEVICE TEST REPORT 0 REPLACEMENT
NAIME
3 X55 472o Sri ! - `
STREET �—
R"
CITY ZIP N ''
DEVICE M"E 94G J MODEL IV 101� 7I 1SIZE l I I I I
SERIAL
WATER SYSTEM NUMBER
LOCATION L ([« of Of
LOCATI . �* � --- --- r"`
RED ED PRESSURE DEVICE I PRESSURE VACUUM k '
INITIAL TE;/
DOUBLE CHECK VALVE CHECK •1 BREAKER PASSED Ei
CHECK 01 CHECK 02 AIR INLEf CHECK FAILED ❑
MililAl wrNru A OPENED AT PRESS DROP DATE IQJ b AA ff
TIGHT d TIGHT RFI�F�r
TEST oa ,•L Ino 1 J•. Irmo
LEAKED ❑ LEAKED❑ RELIET VAI.VE
PRESS DROP PASSED ❑ DID NOT LEAKED
_ 1•. Irmo FAILED ❑ UPEN ❑ ❑
REMN8
AND/dl
MATS '
I PRESS DROP AFTER REPAIR 1?�.
TEST LJ•I_-jpn OPENED AT PRESS DROP DATE.W L_LlW
AFTER TIGHT Cl TIGHT ❑
REPAIR RELIEF OPEN
I_l i• _JMmo L1_-;•1_JM
L_iJ•LJreo
DETECTOR METER FIELDING
IN COMPLETING AND SUBMITTING THIS TEST REPORT,THE TESTER CERTIFIES THAT THE
DEVICE HAS BEEN TESTED AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE
RULES AND REGULATIONS OF THE WATER SYSTEM OWNER AND THE STATE OF OREGON.
STERS SI TURF GAUGE N CERT N A
REPORT RECEIVED
BY (REPRESENTATIVE OR FIRM) I.
WATER SYSTEMS LOPY
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•
17742E
❑NEW
BACKFLOW PREVENTION DEVICE TEST REPORT ❑REPLACEMENT
I IRM
NAME ___ 1 �_-_ .. SL�_-.__. —._.--_—.
DEVICE
ADDRESS // Gy CRC_
—�j*Ld--cITY - ZIP
SIZE L-.`1•lQ1QJ ��E � MoDELLl2I I I 1 1 1 1 I I I
SERIAL I I,I,lI I V I I I I
WATERSISTEM NUMBER
DEVICE �` 3-�
LOCATION I tCC. "/L� G�'u
REDUCED PRESSURE DEVICE PRESSURE VACUUM INITIAL TEST
DOUBLE CHECK VALVE CHECK ►T BREAKER PASSED
CHECK •1 CHECK N2 AIR INLET CHECK FAILED ❑
- r
OPENED AT PRESS DROP DATE 611
MRAL TIGHT TIGHT RELIEF OPERED AT
lip L!•'._1n1A Jn10 1 J•!_ •c�
RELIEF VALVE
LEAKED ❑ CAKED❑
PRESS DROP PASSED ❑ L�I C NOT LEAKED
..J•UPso FAILED ❑ OPEN ❑ Cl II 4
REPAIR
AMl!'(ii
PART; y
•I PRESS DROP AFTER REPAIR
TESL L1J•IJno OPENED AT PRESS DROP DATE ; i I I LJ'LLJ
AFTER 116111 ❑ IIGH-r ❑ k�
REPAIR RELIEF OPEN pf
•i. I►fD U
I_!__l•'i ;Cao .�.
,I
OF FCTOR METER READING al'
P., INCL VLETING AND SL 'BITTING THIS TEST REPORT,THE TESTER CERTIFIES THAT THE
DEVICE HAS BEEN TEST'D AND MAINTAINED IN ACCORDANCE WITH ALL APPLICABLE '
RULES AND RE:GULATIEM OF THE WATER SYSTEM OWNER AND THE STATE OF OREGON.
STE qTU GAUGE CERT#
REPCIRT RECEIVE
BY: IREPRFSENTATIVE OR FIRM)i
WATFR SYSTEMS COPY
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