HomeMy WebLinkAboutCarmel Retail - PFP Certificates - 7241,-�--
City of Fort Wayne
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Cross Correction Control & aackflow Prevention Program
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BACKFLOW PREVENTION DEVICE - TEST & MAINTENANCE REPORT FORM
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Properly Name
Service Address'
Street s'
7 a 4Y I I
Street Prefix C Street Name
146 fH 47 T
City
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State IN Zip Code
I Business Type
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Firm Name}
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Firm Address
(OM /M�erCe oV'
City
��l111 jlq (0a
State
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Zip Code
1 Z16 J-0
Phone#
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E-mail:
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Serial'
u I 7 9
Serial #
Manufacturer'
tN I (�/H Z trip M
Manufacturer
9 7 k L
Model #'
Model #
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Device Size'
Device Size
C, n G N y <,G i"
/'UUlM
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Location'
Location
AIR GAP, Inches Above Rim
F-7
Supply Size
E=
At/tic Cpened Fully?
Yes ❑ No ❑
Domestic Containment Service
CHECK `!ACNE NO I
CHECK VALVE NHO 2
3IFFERENTIAL PRESSURE R.3LIE'r VALVE
AIR INLET
Fire Service andlor By-pass ❑
Irrigation Service ❑
closed tight
leaked ❑
closed fight LAC
leaked ❑
opened at psid
did not open ❑
opened at psid
check valve psid
Secondary Isolation Service ❑
paid f, Z-I
psid t•
leaked ❑
leaked ❑ closed ❑
cleaned ❑
cleaned ❑
cleaned ❑
cleaned ❑
I, Irv,
RP P11B
RPDA ❑ ❑ S118
DC ❑ ❑ AVB
DCDA ❑ ❑ AIR GAP
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Printed Name
ez t IDEivI Certificafion;
T70 a,9 1 V
Passed lkr
Signature'
E-mail`
Repaired & Passed ❑
Failed -Refused to Repair ❑
Phone #'
U , y 3'�//• 57 ! G
Failed -Will Rapair.'Replace ❑
Test Date'
h V
Test Kit'
too t ;I-V
I Calibration Date`
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