HomeMy WebLinkAbout6607 Yuma Pl - Special Inspections/Backflow - 06/21/2000or
RECEIVE
Q
JUL 2 7 2000
Oo /25 3 �
BACKFLOW PREVENTION DEVICE TEST & MAINTENANCE REPORT
Water Supplier/Aut rity:
n
MeterlAccount No.
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«Service Name: i s- c- l R
Street: (o . O
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n.-S Stater_ Zip: Q 5 Z�
t- City: o4ci
Contact Person: 5.8•E
Title:
Phone:
-Owner/Mgmt. Co./Contractor:
Street:
City:
State: Zip:
Contact Person:
Title:
Phone:
c Existing: O New:
Replacement For:
USE: Domestic: ❑ Fire: El Irrigation: /r
O Double Check I
Isolation: ED Containment:
Pressure Vacuum Breaker/
4Device type: Reduced Pressure
_
Manufacture:
Model: 7 A-
Size: % Serial No: 5 ] -'-
�• - l6 —U o '
��
Dat�e��
Last Ins pectionlTest:
Main Line Pressure:—�,�PSI ,
t �Installed:
�Loceition on Prorterty:
�Dv T�f SipL
of ✓ sf
c
0
4
C
q�
6
O
lt:
b
Djral Check: Checks tested at min or i.0 psi _._Replaced checks
0
m Device Mechanical Test: Pass X Fall O
u Fads StatelLocal Standards: f__!
Installation: Meets State/Local Standards LQ
C Exnlat, in failurp/Repairs.in detail' - ------- ----
,N%
Person notified of any failure: -- ---- - Title:
Alarm Company/Fire DepartmentNotified:
a Turned off: Date: Time: Turned on: Date: Time:
This Technician Cortina* this Device has been tested In accordance with
the most recent Edition of the Colorado Cross -Connection Control Manual.
Tested By: 1 � ^® Cert. No. 1 LS- Expires: S-1>-a/ . ,
a. Company: ,¢dfi Xe .r d_ ii-k- Phone: 35-.1 -IY(.Z
c
Street: _,L2 �1 2-1 tr City: tLE �_L� . _... State: Q) �ZZIP.-
0 Test Equiptment used: L� Last Calibration Date:�rT L''or
•Technician: ____ __
Date: �Z o Time: 3 f An l
p rgna ure
Time:
Device Owner or Agent __ Date:
Signature r
Rev 8/94 Keep test form on file loi n i w, i , or "tree veers