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OS/?7/2015 5:0T P4 P.1R 425374&4b3+� y w� vuvoivou� � <br /> i <br /> BACKINA i ER PREVENTION DEVICE FIfVAL i <br /> IiVST,4LL.�ITION CHfGKLIST � <br /> ; <br /> InstzlfaGon Company Name and CoNact Info:� � � ! <br /> tG.rS�,�{i� � i <br /> Date B2CY.vialer Prevenpon device BVJD �sas inslalled: p n.S�� � <br /> ( ) Date this form v�as ccm 19Ibd: <br /> fnsfalleGonPropsly0wnerName�ndConfactlnio:_N�asz� „� r��,-,�, <br /> �. <br /> Prop2rryt�dres>:_Ilp�j�(o,,_ (�.tQ_`��r�{ C '7f� 'rj'�- 7/ � <br /> Prednstallation Inspeetion Checklist: , <br /> /�11 items musf be checked'Yes'In croer lor a B WD(o bz�ronsldered(o;Instellafion i <br /> Is lhere a bas?ment or level o`Ihe hou:e thwt is ai o�near assumed se�A�er main elevaGon?�Yes ❑No � <br /> Are ihere flzture9 in the house Iccated befo��lhe upstream sevrer manho!e rim elevaBon?�Yes ❑No ; <br /> is Ihe Side.SE�vercurrently UNPRQTcCTEp from eev:er backups(doe9 nOt have a 9th'D Ir�s!alied)?� Yes ❑Np � <br /> Site Inspection.Checklist; ; <br /> All rtems fiust bs checl:ed Nes'before inspection is co,uiaated compfete ' <br /> Wzs side serrrN inSpeCtey�`�om building tosevaer main? Q Yes ❑No Condilion: � <br /> Dc�:s side sea,�er haveahleast 14'o slcpa Gcsm;fie buiiding lo sewer main9 �Yes Q Nc Descdhe� <br /> Have ali building sewer drain connec5ons to IhA side se�xer been Idenlifi�d snd loca(ed? [,�Yes 1]No � <br /> Ha+e ail pioperfj storm dcain3ge conn:ctions t�thasidesewer tMen identifieJ and located? �Yes []No � <br /> � <br /> Nzs property b=En evalu;,}Ed for d�ainage defiC'�enqes�:�ith 5ndir�gs Wmmunicaled to propedy cwne�? �Yes ❑:No � <br /> Ins�Ilatioh Details: ! <br /> '1!hat�y�e and bran'd of flNrp,y�as instelied at inis site(Clean Check BWV; Grind:r pump,e�c:): G�2GAn ChPI'�. I <br /> 'A�here�yas;h'e device installed(gener2f deScrptioh;�ch lnap)? _btA��(�„(, (1A}1�.pL � <br /> 1�'as Jfiert�any ofhersewer or siorm dreinege;v:ork aimpleted In conjuncLon�viti�thR 9W0�vork? Is so please nescrine: ! <br /> � ' <br /> � <br />� <br /> InstiQatioo Checklist• � <br /> fve a�do�vnspoufs and site drainaye disce��netted 5om upstream of the B�A�D? �j Yes ❑No Commonts: ' <br /> Does BNlU CioslGoning meelsminimum slo�requiremeni cf>t�'o? �Yes ❑No Comments: � <br /> Can t3N�D�piAled out tor inspectpn and rtwinienance afier Ioosening thunb screvf� �1'es. ❑No i <br /> is B�NplpCfcc�l inlo Iheproper�sitiqp.ar,daluW�istrew fighlened? [�Yea ❑No I <br /> Circl.ihe BVJD cover.irngaflon c�ar.(lanescape a a �a�ic bad 6e2ting cover(driv:sur(ace),I aCce�hatCh(6uiltling) • <br /> lh'a5 properiyavmersho�m�he locaiion u ie instalied pWD7 gf Yes ❑No Comments � <br /> �Property Ownefs Signa;ur�:. �•/ ,^ Dale:_p��J�z� S ' <br /> /� �—._._ <br /> Inslaller's S'�r�ur!;;��r ` y�-v�.���— Da�c: i <br /> Reylsion:2. . I Frlday,Sepie�nc�r 12,:2014� � <br /> i <br /> i <br /> . _. i <br /> � <br />