HomeMy WebLinkAbout3902 Big Dipper Dr - Special Inspections/Backflow - 11/08/2006es4e.__ cipe�� (B 6
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DATE OF TEST I I l r6 /Q(p ��L'EXISTING ❑ REPLACEMENT ❑
,do G. d z Y,rL NEW 09 PERMIT #SC`t Q245 Z
BACKFLOW PREVENTION TEST REPORT
RETAIN THIS REPORT THREE YEARS FOR YOUR RECORDS
OWNER INFORMATION
NAME /'4% GH A C(L t-c.-)2 C_STc--2 TELEPHONE AqA) Z $Z - c)7 6?
SERVICE ADDRESS 3av2 B ic-, -0(C'PFR- r)(2,
BILLING ADDRESS 5AM f CITY Fo(zT CO LL_ (tiS STATE/ZIP C(') $ 0S Z %
WATER SUPPLIER -lPcvR r -C-G;f6 Lj 0-'s CONTACT PERSON
DEVICE INFORMATION
W IRRIGATION ❑ DOMESTIC SUPPLY ❑ BOILER ❑ OTHER
MANUFACTURER Fear-0 MODEL# 7b5 SERIAL# H 3'304t34 SIZE 3/1-1 �
LOCATION OF DEVICE FAST 51 Or Or HOU.
TEST INFORMATION
I1) PRESSURE VACUUM BREAKER
AIR INLER OPENED AT 2,y P.S.I
CHECK VALVE TIGHT AGAINST FLOW?
❑ REDUCED PRESSURE ASSEMBLY
1 ST CHECK WITH FLOW P.S.I.
❑ RELIEF VALVE OPEN
2 ND CHECK TIGHT AGAINST FLOW?
❑ DOUBLE CHECK ASSEMBLY
1 ST CHECK WITH FLOW
1 ST CHECK TIGHT AGAINST FLOW
2 ND CHECK TIGHT AGAINST FLOW
f9 PASS ❑ FAIL
NOTES:
Up YES ❑ NO
_ P.S.I.
❑ YES ❑ NO
P.S.1
❑ YES ❑ NO
❑ YES ❑ NO
SUPPLY PRESSURE G�C) P.S.I
CHECK VALVE WITH FLOW 3y P.S.I.
2 ND CHECK WITH FLOW P.S.I.
2 ND CHECK WITH FLOW P.S.I
PERSON NOTIFIED
COMPANY INFORMATION
TESTING COMPANY FORT COLLINS SPRINKLERS INC PHONE # 223-5625
ADDRESS P.O. BOX # 2202 CITY FORT COLLINS STATE / ZIP CO 80522
GUAGE TYPE ORANGE RESEARCH (5 VALVE) LAST CALIBRATION DATE _!
TESTER s iJcR )N / CERTIFICATION # CO'-1 0EXPIRATION U_30jp�
SIGNATURE "_*tsA _k.Kd.,n
10 'd ZVPnIVOL6 S3Iillfill SNI1100 180.E WV 8£:60 IN. 90OZ-Ll-AON