City of Toledo - County Fire Protection

City of Toledo
Department of Public Utilities
Water Distribution
Backflow Prevention Assembly Test Results
(Revised 6/07)
Containment devices are required to be tested when installed and at a minimum of every twelve months
thereafter. This form is specifically for containment devices and after completion should be returned to:
Backflow Prevention Coordinator, Water Distribution, 401 S. Erie St., Toledo, OH 43604
Facility Name:
Facility Address:
grr:/
/70
/kJ • &ItIt I e.
Contact Person:
Phone Number:
Hazard (circle one):
Fire Suppression System
Irrigation System
Device (circle one):
Double Check Valve
Air Gap
Manufacturer/model:
it/(77r
Fe'?
Size:
Serial Number:
•,,,,,
'AY
DoUble Cheek Valve (DCV) Assembly
1st Check
2nd Check
psid
DCV Initial Test
RP -
p. 9
psid
DCV -
(1/0?-3C9
Relief Valve
psid
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RP - Closed Tight? Y es or No
Opened at .1, t
psid
Repairs and Materials
Used
DCV -
psid
DCV -
psid
Opened at -
Final Test
RP -
psid
RP - Closed Tight? Yes or No
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Remarks (Describe deficiencies such as outlets before the device, bypasses, missing or inadequate air gaps, etc.):
Business Name:
Testers Signature:
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Phone Number: ,f30'
Us. /0/q
Date:
(7/06`-(1
Certification Number:
Testers Name:
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City of Toledo
Department of Public Utilities
Water Distribution
Backflow Prevention Assembly Test Results
(Revised 6/07)
Containment devices are required to be tested when installed and at a minimum of every twelve months
thereafter. This form is specifically for containment devices and after completion should be returned to:
Backflow Prevention Coordinator, Water Distribution, 401 S. Erie St., Toledo, OH 43604
Facility Name:
7(0
Facility Address:
A.J
e
5I
Phone Number:
Contact Person:
Hazard (circle one):
Fire Suppression System
Complete Buildin
Irrigation System
Device (circle one):
Double Check Valve
Reduced Pressure
Air Gap
Size:
Manufacturer/model:
5---4/7e3
Serial Number:
400 Ch eck Va.0,0,-(Devyms-01.bly
2nd Check
1st Check
psid
DCV -
a
9
RP -
Initial Test
psid
DCV -
Relief Valve
psid
Opened at -
RP - Closed Tight? 0 or No
3 'C
psid
Repairs and Materials
Used
psid
DCV -
psid
DCV -
Opened at -
Final Test
psid
RP -
psid
RP - Closed Tight? Yes or No
Remarks (Describe deficiencies such as outlets before the device, bypasses, missing or inadequate air gaps, etc.):
Testers Name:
S-77/c-fri t
Business Name:
C--)rd
Testers Signature:
gy
,
At
.77sJ
4“:1474.4.`g-il fel /6
Certification Number:
Phone Number:
Date:
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677- to At
6 -,/
City of Toledo
Department of Public Utilities
Water Distribution
Backflow Prevention Assembly Test Results
(Revised 6/07)
Containment devices are required to be tested when installed and at a minimum of every twelve months
thereafter. This form is specifically for containment devices and after completion should be returned to:
Backflow Prevention Coordinator, Water Distribution, 401 S. Erie St., Toledo, OH 43604
Facility Name:
6
Facility Address:
k!)
Phone
Contact Person:
Hazard (circle one):
Fire Suppression System
Device (circle one):
Double Check Valve
Complete Building
Irrigation System
Air Gap
0,/
Manufacturer/model:
bej
Size: Zvi
Ad 6 XPZoS-'
Serial Number:
Relief Valve
psid
DCV Initial Test
RP -
6•0
psid
DCV -
psid
Opened at -
RP - Closed Tight? 0 or No
ok.M
DCV -
Opened at -
psid
Repairs and Materials
Used
DCV -
psid
psid
Final Test
RP -
psid
psid
RP - Closed Tight? Yes or No
Remarks (Describe deficiencies such as outlets before the device, bypasses, missing or inadequate air gaps, etc.):
Testers Name:
Business Name:
Testers Signature:
Certification Number:
,
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a It4 X C._*{:3i
Phone Number:
Date:
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City of Toledo
Department of Public Utilities
Water Distribution
Backflow Prevention Assembly Test Results
(Revised 6/07)
Containment devices are required to be tested when installed and at a minimum of every twelve months
thereafter. This form is specifically for containment devices and after completion should be returned to:
Backflow Prevention Coordinator, Water Distribution, 401 S. Erie St., Toledo, OH 43604
Facility Name:
s:
lj 67
Facility Address:
/0 • 642
Contact Person:
Phone Number:
Hazard (circle one):
' e Suppression Systerr
Device (circle one):
CDOuble Ched
—c—V—ai-j—
te.))
Manufacturer/model:
"9
wi e S
DCV -
Irrigation System
Reduced Pressure
Air Gap
/ .3600-5_5
(N7 • a
psid
RP -
Initial Test
Complete Building
psid
DCV -
Size:
S
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Serial Number: 1 /-, ey 93 OtObi
psid
Opened at -
RP - Closed Tight? Yes or No
psid
Repairs and Materials
Used
DCV -
psid
DCV -
psid
Opened at -
Final Test
RP -
psid
RP - Closed Tight? Yes or No
psid
Remarks (Describe deficiencies such as outlets before the device, bypasses, missing or inadequate air gaps, etc.):
Testers Name:
Business Name:
Testers Signature:
• 7"
00'0
,4
01 12 4 c 0.4,c)AL("CiA
7
-
Certification Number:
Phone Number:
Date:
6o tog
:330-6_?3- /4
City of Toledo
Department of Public Utilities
Water Distribution
Backflow Prevention Assembly Test Results
(Revised 6/07)
Containment devices are required to be tested when installed and at a minimum of every twelve months
thereafter. This form is specifically for containment devices and after completion should be returned to:
Backflow Prevention Coordinator, Water Distribution, 401 S. Erie St., Toledo, OH 43604
Facility Name:
/0 7;
Facility Address:
P/
e
A.)
4.3c9
5T
Phone Number:
Contact Person:
Hazard (circle one):
Fire Suppression System
Device (circle one):
Double Check Valve
Manufacturer/model:
6o
C0
(Complete Building
970DetkC'rc-.'1
Irrigation System
educed Pressur
Air Gap
f
Serial Number:
Size:
gthAyso
Relief Valve
DCV Initial Test
RP -
psid
7 ' (-1
psid
DCV -
psid
RP - Closed Tight?
0
Opened at -
or No
‘0 6
psid
Repairs and Materials
Used
DCV -
psid
DCV -
Opened at -
psid
Final Test
RP -
psid
RP - Closed Tight? Yes or No
psid
Remarks (Describe deficiencies such as outlets before the device, bypasses, missing or inadequate air gaps, etc.):
Testers Name:
e Vt.
Business Name:
U
Testers Signature:
v141 F ■
Certification Number:
Phone Number:
Date:
- 7,?(>
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