HomeMy WebLinkAbout4437 Stover St - Special Inspections/Backflow - 10/14/2000�wa o.Jt C ka nT� .i✓ot^rAoe D
a O�'cS aeamvoeY1 rv{ 516 E. 7th Street Office: 970-613-8853
Loveland, CO80537 Toll Free: 1-888-287-6986
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Backflow Prevention Device Test & Maintenance Report
Water Supplier/A
Service Name:
Street:
Contact Person:
Owner/Mgmt. Cc
Street: ,!; 2 /;.
Contact Person:
- V 4 -1 e,' / j / W 3- Meter/Account No.
No.: e{ J e:-7% % QgO
City: , d TIL 'Q ' ' State: CO Zip: tl�()_
Title: / vJf'1I r- "r- - Phone: a? 7 ;t 2 9,
Ma c 4--) A.)
City: S State: (? jO_ Zip: g0_T
Title: Q ;,,>ru er'Z- Phone: d06
Existing: L] New: Ja Replacement For: Installed: Horiz. Uk Vert. ❑
USE: Domestic ❑ Fire:❑ Irrigation: Isolation: Containment: ❑ Process: ❑
Device type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breakerj& Other:
Manufacturer: r- e- h C- 0 Model: :2(. S Size: �_ Serial No: 4
Date Installed: n_ 0000 Last Inspection/Test: N Main Lire Pressure: _:r 5 PSI
Location on Property: 5n c �'� i Ci' e n I G i k4
Reduced Pressure
Type
Double Check
Type
Pressure Vacuum
I Breaker
Re -Teat
Leak
Spring
Leak Spring
Leak Spring
Leak
Spring
Tightness
Tension
Tightness Tension
Tightness Tension
Tightness
Tension
Air
Inlet
PSI
1 PSI
Check
❑ Tight
❑ Tight
j$7ight
#1
PSI
❑ Leaked PSI
❑ Leaked PSI
❑ Leaked
"PSI
❑ Tight
❑ Tight
Check ❑Tight
#2
❑Leaked
- PSI
-❑_Leaked PSI
❑ Leaked-
PSI -
Relief
Valve
PSI
PSI
Buffer
Zone
PSI
PSI
Shut Off Valve No. 1:
Leaked ❑ Tighpl—
Shut Off Valve No. 2:
Leaked ❑ Tigh
Device Mechanical Test: Pass 0Fail ❑ If Mechanical Test fails, the water authority must be notified immediately and repairs
made as soon as possible.
Person notified of any failure: Title:
Alarm Company/Fire Department Notified:
Turned off: Date: Time: Turned on: Date: Time:
Technician certifies this device has been tested in accordance with A.S.S.E. Procedure 5010 - r' D
Tested By: Lynnette Keim Cert. No. 1687 Expires: 5-2003
Company: Quality Water Phone: 970-613-8853
Street: 516 E. 7th Street City: Loveland State: CO
Zip: 80537
Test Equipment ed: Mid e t 830 Last Calibration Date: 4-13-00
Technician: Date:
Device Owner or gent: Date:
Keep test form on file for minimum of three years