HomeMy WebLinkAbout5632 Cardinal Flower Ct - Special Inspections/Backflow - 08/21/2009Water District/ Authority: Account: Contact Person:
Facility Name: _ Contact Phone #: _
a.
u Service Address' �zf G
Mailing Address:
Owner Manager ❑ Contractor ❑ Other. Contact Person:
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Company Name/ Title: ontact Phone # - 673 --- C 7 9
Q-' Mailing Address: g ('��;2 f c�v 6C�E (�s��i /t
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Make CU Model:
� Type: 0 RPZ ❑ DC PVB ❑ SVB Air ap 0AV1B 00ther
Date installed: Location on Property:�-
J°' Orientation Service
` (Only if Applicable - Include Previous Serial#)
Protection
❑ Replacement Assemblymeet.. outlet. ❑ Domestic
New installation � ` ' _t r T Vertical Up t ❑ ❑ Fire
❑Containment
❑ Isolation
'❑ Stolen t t ❑ j Vertical Down j ❑
❑ Containment
/b(lrrigation
Previous Assembly Serial # o -> Horizontal -a ❑Other
By Isolation
`Line PSI: ±initial Test Results ! Repaired: ' Cleaned: ^ --- ` - ---
' --Re-Test Results -
Tlghtness'Dlfferential Ck#1❑ Ck#2❑ Ry❑ ! Ck#1❑ Ck#2❑ RV❑
;Tightness; Differential
_ _
(Check Valve #1 .. ❑ Leak Ck#1
❑Leak f
�(CW: RPZ,DC.PVB,sys) KTight ;disco springo seato other. _
❑ Tight
Check Valve #2 ? ❑ Leak I Ck#2
(Ck#2: RPZ. DC) o Tight idisco springo seat❑ other.
Relief Valve ( i1RV
io Leak
❑ Tight
!
c. (RV: RPZ) !diaphram ❑ seat❑ other.
I i
Buffer f Repaired: Cleaned:
R` ((RPZ) j \ Air Inlet ❑ Air Inlet❑
_: jAir Inlet ` Air inlet
m E
(Air inlet: PVB,SVB) ; ❑ bonnet❑ other.
F
\?
poppet
—
i
Shutoff Valve #1 i o Leak i Tight ! SOV #9 Open Upon Arrivalm Open Upon Departure: ❑ BaclTressure Exists? Yes ❑ ido
'-CShutoff Valve #2 j❑ Leak )(Tight SOV #2 Open Upon Arrival a Open Upon Departure. j Cause:
-
Assembly Concerns: !Test Procedure: !Comments:
(only If applicable)
fF Incorrect Installation? ❑ {ABPA O ASSE
1.1-,1 Incorrect Use ? a
r, �Turn Off Date: / / Turn On Date: / /
Turn Off Time: Turn On Time:
rAlarm Company/Fire Department Notified:
Person Notified: Contacted B
zr: Turn Off Date/1 ime: Turn On Date/Time:
,yY `Test Gauge Make: Model: - Last Calibration Date:
/ /
I hereby certify that the Isolation / Shutoff Valves (S(YV#1 and SOV #2) have been returned to the position in which they were found and that the test was done according to the
procedure shown above required by the Water District/ Authority shown above; and the test readings are true and accurate to the best
of my ab0ity.
y^ 'Testing
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�� Yi ^—Phone ��
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Company. c #
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Customer tdame:
Phone
Tester Name: r-� (Please Print)
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Rv (Tester) (Customer)
r,_>>Signature:��'/�%v„fSignature:
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