HomeMy WebLinkAbout1114 Turnstone Ln - Special Inspections/Backflow - 09/26/20063335 Woodlands Way • Wellington, CO 80549
(970) 568-4100
BACKFLOW PREVENTION ASSEMBLY TEST & MAINTENANCE REPORT
INSTALLATION: NEW: EXISTING:_ REPLACEMENT FOR #: PERMIT #: ��! L.6 1 D 11.
DATE OF THIS TEST: I O --4i a, TIME:_-q Q/f�, -
SERVICE ADDRESS: _I 1 1 4' j u f A GJ� LAA-z CONTACT: -:j (.Y1/t
BUSINESS NAME: PHONE: !bD ZZ?b , %i+d4
MAILING ADDRESS:
CITY: AW-E STATE: GD ZIP: 052L+
THE CROSS -CONNECTION CONTROL ASSEMBLY DETAILED BELOW HAS BEEN TESTED AND MAINTAINED AS REQUIRED BY THE
REGULATIONS OF THE WATER SUPPLIER, AND 1S CE/RTIrFIED TO COMPLY WITH THESE REGULATIONS.
DEVICE MAKE: 4LIt
I -1% DEVICE MODEL V J I SERIAL NUMBER: I '� 77 4- 1 SIZE:
LOCATION ON PROPERTY: mAh imaf
REDUCED PRESSURE ZONE ASSEMBLY
PRESSURE VACUUM BREAKER
FIRST CHECK
SECOND CHECK
RELIEF VALVE
AIR INLET
CHECK VALVE
DIRECTION OF FLOW
PSID
DIRECTION OF FLOW
PSID
PSID
L PSID
FIRST TEST: 2. S
SECOND TEST: PSID
REPAIRS
REPAIRS
DOUBLE CHECK ASSEMBLY
FIRST CHECK
SECOND CHECK
DIRECTION OF FLOW _PSID
DIRECTION OF FLOW _PSID
REPAIRS:
NAME OF PERSON NOTIFIED IF UNIT FAILED AND NOT REPAIRED:
WATER PURVEYOR JA n 'A 11i ry
LINE PRESSURE: h 0 PSI
PHONE:
BACKFLOW PREVENTION ASSEMBLY TEST
PASSED FAILED GAUGE TYPE IM16ST CALIBRATION DATE U
CERTIFIED TESTER I CERTIFICATIONy�# _�4_ EXP. DATE
SIGNATURE T-- 07 DATE _ .�'uo(o
ZO 'd aW91VOL6 S3I1111 A SNI1100 180A WV 90:01 NOW 900Z-£1-AON