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Home My WebLink About5409 Belvedere Pl - Special Inspections/Backflow - 05/02/20014 Olson IRRIGATION INC. :hI BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT Installation: New: Existing:_ Permit ,; Phone: 4iqt-q -71o2 Service Name: Service Addres Mailing Address: VrsU.U; �J�CGa,a ,� ,1C.�?.� �� C Aif-K yA S#- [ I City:_ �I.i « t; State: _ zip: -7c Contact Person: "- \ f"'ck^(,k Title: Assembly Make: `C�^C.i� Model: J Serial#: 2� .�rG.� size: IL — .Location on Property: . Water Supplier: _ Test Procedure TESTS FOR DOUBLE CHECK AND REDUCED PRESSURE ASSEMBLIES Direction of Flow: Check $1: id Y�}�,: Check #2"5:�+�, paid Relief Valve: �- Leak Tightness: Check I�1: Tight: Leak:_ Check #2: Tight: Leak:_ TEST FOR PRESSURE VACUUk BREAKER Check Valve: paid Leak Tightness: Tight:_ Leak:_ Air Inlet: Pass: Fail: REPAIRS AND COMMENTS Line Pressure: 4s — Repairs: d R �_ Comments: - THIS TESTER CERTIFIES THIS ASSEMBLY MEETS MINIMUM STATE AND LOCAL SPECIFICATIONS Tested By: 'Epic C>Lc,:,o� Certification #r I'47JI Erpires: WCO Gauge Tye: : _ g yp '� q� E Last Gauge Calibration Date: 3 d Date of Test: �' �� Tv*me of Test: jj, Tester Phone Number: Tester Signature:pier or Agent Signature: ANNUAL RETEST REQUIRED WHITE COPY -OWNER YELLOW COPY -WATER UTILITY PINK COPY -TESTED