HomeMy WebLinkAbout2002-07-01 Backflow Preventer Test Report 07/08/2010 13:40 6517839324 PAGE 03
D11/01/2002 22:57 651498 MODELL .......C.„ FI Nb
REDUCED PRE. _:JRE BA CKFLOW PREVENTER
TE ZEPORT AND
TESTABLE DOUBL ,
SAINT PALL REGIONAL WATER SERVICES ,•
`44
Service Name: y iti,1f)i 50,.4_,±1,•-, Contact Person/Tele —i— }
/address: gC? , 3*
5� • ,Ai• city: Oak-Pk. (-> s- State;J�,fll .zip: 'v
N o to 5 C Serve what system: �t.or, jr r1 a �"�"' -- 3
Device Location: 1►1 � 1 1 Q� ��
Account Number;_,,, — Serial Number: _J f N.
Wake:�A, _L T Model Size: _Lel.— g r
Type:
Install Data: Air Gap Installation Datev,,4
Rebuild Date' _ __-- Test Date: 4;Y
;-
+ Check Valve#1 C__ne``ck Valve Art Differential Pressure Relief Valve
Annual close . C✓t 05e o Se
"� it.Report Pressure 9 •7 Pressure C Opened at 3-9 psid reduced pressure.
Did net open
Cleaned --
Cieened Cleared
Replaced Replaced Replaces
Disc Oise pisc,Upper:
R -
E Spring
Spring Disc,Lower
P Guide Guide _ Springy
A Pin Retainer —____, Pin Retainer Diaphragm,Large
I Hinge Pin
Hinge Pin Lower
Seat Seat L��
Gea
R Diaphragm Diaphragm.Small
S _ Dlaohrcm
Other, describe Omer. describe ___.r, Lower
Upper
Seat
Lower
Upper
_____, _ Spacer, Lower
Other,describe
L�� Sign and date Tag Q ,
The above is certifisc correct. Signed mac'"^
ta) rook--" CateTested: 7
Tested by(Pi-int Name) \fj Cl r r P v1
AA.o i e f 1 Certification Number t L
fi
Vit, e .. License Number
Company Name: -� - �02 Vit, )
Company Telephone Number Jg„51 72 --...3.5-S .5- ,
All sections of this report must be completed. Number of Devices fee oer Deyice
$ 30
Return to, Saint Paul Region&Water Services First Devices 2-21 $ 20
8 4th St E Ste 400
5
Saint Paul, MN 56101.1001 22 and over $ 15
Ft®
cum with fee: payable to the Board of Water Comrr.issioners