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HomeMy WebLinkAbout2603 Ashland Ln - Special Inspections/Backflow - 06/07/2007BACKFLONV DEVICE TEST REPORT ?{J's Bac f&w Testing L1C "Y.:wC ©m-Cwrntcnnn Ccrnuaim' 1540 27th SL, Greeley CO 80631 • (970) 352-3090 or (303) 951-7032 Cell WTR Dist, Meter # No. 5173 Owner Semice Address �' ' AsAk-ild Ln f 4-6)/7,L Mailing.gdd ess/ Fi r77ccrnd met cF 3 7 /�� ,� /q V2 C lL ear z,S/ l Contact _S`�. V lox, Tide; Phoric: 1 55' 1 77 RP C DC C P 1V'B K CONTAINMENT ❑ ISOLATION C DOMESTIC ❑ FIRE ❑ IRRIG.ATfONX PROCESS ❑ AFG. fc'.r�F'1aS MODEL %ram/ SIZE�SERIALNO. 174C'cn,72�� LINE PRESSURE -�> DATE INSTALLED �y "� %_ LAST TEST LOCATIONt� Existing C INITIAL TEST REPAIRS RE -TEST ' N09 I Ti t '.2 r- PSID TIGFIT ❑ PSID N04 2 Ti t PSID TIGHT El PSID RELIEF VALVE PSID RELIEF VALVE PSID BUFFER PSID AIR INLET PSID BUFFER PSID Shut off valve # 2 Tight I Din of flow ❑ horizontal AIR INLET PSID ❑ up ❑ do TEST DATEA�C " THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES: ASSE 5000 TEST PASS:1G� .AILED: ] TEST KIT: /�I / 4 - L[,FyS'f 4'N-5 RE-CAL1B DATE: ADDITIONAL CILARGES: COMMENTS: / BY WNnna TIME TURN•EDD OFF: / � ^ TIME TURNED ON: CERT r CERTEXPIRES: �- c TESTER: ACCEPTED BY: ALARM CO/FIRE DEPT. NOTIFIED: Sipaturc TESTER: CONTACT: Tinte�t s� Signature Si6ming this report verifies that the isolation val•.•es are in open posi:ion 1 certify under penalty of law that I �ulve persmally perfomted lb tes: irnpeclions erne tepai� suhm;ncc and the fire alarm is functioning. You agree to pzy a finance charge cr on this form. An test procedures ut:rc performn d N zcxonlaoce with the latest edweit)m of the ahm.neColomdr. I "5o per or a minimnn of SS.OD whieac rr is more on imoiccs that are Croc.-Connection Manual. I helicte the submitted i"'erm:nion is true, acccra:e• fe complete. I am aw•aM Thirty (30) days past due. That there are significant perualfes for submitting false information including the possibility or fines or itnp isonment. OWNFR WAT AD Tra•rn rrr m.-.-__- Z•d b6L999£OL6 uosuowig e1uu08 d6Z:tO LO LO unf