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HomeMy WebLinkAboutbackflow test������-"•,-�',y�:ih.l} �F'SVdifQ�lSal:US'llf ��LS:ii7Q�LSi,���c?7� r �`';�,�%��.= SlrytaPol'm6Glo0(7.-iS) � .\,.r; �: • , q ��q �_. II fDIAIVA b�pAEtTMEI�T OF ��IVIRONMEf�I'N. MANAfl[A1CNi INlS.F'�,�21U11S 7t116�{ �OlUIPd.��'E'U e�YAllf !N!�ll1N.��1 �L:RTlI"1�17 BACKF�.(1U1l7'�,47�R. ��;.'! 4� .j:.. 6 D. '�11 � 1! .. 7'l 1 �� � l...1,y c��1: I•u' �y ..a'K� • `�i �� 1�" ?�Q�J.:i7.c_� �" } ., . .�:�. �.'.' , � � a �.' I!�� cA o • ' o i �r�,.{{t �. Cilstotner nama �'���� �, � 2. Cuatomer company , 3. Customor eddioss (number and sfre�t, cify, sfate, and 'Llp code) ��G� c !IG '� s�- ' h Lacailon of d 1 d �el�q— '�Z� 1'.����•�� U'��1�� 1�7.�' ��p ��7;�1 ?� ..._.'.... �. .._ .,. ....., ,n � . evi ce (an addressl(dlffarent fiom customer) 5. Is the devlce a new aesembly? [] Yss ❑ No . r.� Z Gy Re lacin, setial number: F.Type o�` setvice 7. Ty�a pf assembly pomasilc I] �ICe ❑ Irrigation � Rp [� bC [] pVR [�j sV� [j Air Gap ]] �� a. Typo of Yotealion . 9, S�rial number of device � Isofativn ' Confa(nment �) � � z��— � �(U. Sizv o d�vlcA �1�. Manufaciurer ofdevice . '12. Modef number of devlca ; /�n.s � � L 'I8. Addltlonal Infm•matinn /nnfF.,nnll Check Value �9 Initiial UaFe Cmmiddryy): Held at - pSl1] Time; � �] Closed TfghE ' [j pASS [j i,eaked Cj PAIL ' �'izial Dato �,rr✓d�ri�;�� Held at � d PSI❑ 7ime�i ;�+. . . ['� pA55 '�'In�ed 7ight �] L�aked j� �.alt, � Alt� GAl7 Measured verlical tnches above overflow rim : 'I�. Comrrienfs � � C CF�ec;c Valve ��2 I-leld aE PSID [] Ciosed 7ight [( Lealced PressureDifferential � Air(nlef Rp�liraf Vo6ro opened at Opened at Ps1D [�Slp . [j D1d I�fot oPen C] Uid Nat O�en Chec;� Vafva Hotd pSID Held af P51b Opened af ��� dPeneci at p5(Cl P51U �"Closed i7gf�f J�,17id NotO�en [f l,oaked, j� D1d Not Open Cheol<Valvo Held l'�51D No '!6. Name ande-malf address oFfesteP . Inifial .�g, re[ephone numher �19. slgnatura and reg�sfration num x'e�xez� Za. 7esi(ng equipmenEsc�rtal riumbet' 21, T �%.�Oom�pany name of#esfer (if ,t calibi�aiion date (mm/da 22. Namo and e-m�ll address oftester 23..Company hame ofieafer ('�appllcehleJ �ina► �lake Mobley Jake.Mobley�a [<Qorsen,com f<oors�ri ��ire & Sec�.trify 24. Telephona numbo�• 2�. Signature and re�isfr�tion number offes#or 7'esfei� �'17 7'10-3090 13��j�..5r8Q, . 2fi. Tesffn eqiifpmonf serial number 27. 7'esting equipmenf callbra3ion daia (mm/dd/yyJ OQ�16'�499 12IQ41� �,fl1 y j,(�, �y slgning fhfs Udckflowfes� i•e��ol�E and checicing fhTs box,1 hereby cerfit'y that! am familiaruvlth tha into�matiori cu�fainad 3i7 fhfs torm and tha9;�o tTie bes# oi'my Tcnowiedge and belief, such inFoimatton is �•u� �n�npTeto and accaraf� atihe�tirrte of the fesf. ' Pege z oiz