HomeMy WebLinkAbout2474 Thoreau Dr - Special Inspections/Backflow - 06/07/2007 (2)BACKFLOW DEVICE
TEST REPORT
AJ's Bac flow fisting LLC
"Your Cross -Connection Connection"
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
WTR Dist.
Meter #
Owner�.IC?Xh
Service Address .2474 I !1r?/� yet c..+ 1�.,!'
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Mailing Address 4/0✓
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Contact
Title; 'IV,
Phone: Phone: ( c=�5�" ) >/-'; :77i
RP ❑ DC ❑ PVB
CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATION 0 PROCESS ❑
MFG. A,;, l K ll'7 S MODEL
:7-7, ^r 4
SIZE
SERIAL NO.
LINE PRESSURE C.w DATE
INSTALLED
f"k -7 LAST TEST
NEW.Pf Existing ❑
LOCATION
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight X.2. 0 PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET «Z, PZ PSID
AIR INLET PSID
Shut off valve # 2 Tight J '
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE: THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS: FAILED: ❑ TEST KIT: /r�r ..w/ Oc t"5� l%� RE-CALIB DATE: .51e7,�
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED: /V /f- BY WHOM:
TIME TURNED OFF: TIME TURNED ON: .�A +A" CONTACT:
CERT# 71 3u CERT. EXPIRES: /F47 TESTER:
f
ACCEPTED BY: TESTER: /J Time ;;�'67 P7
Signature Signature
Signing this report verifies that the isolation valves are in open position I certify under penalty of law that 1 have personally performed the test inspections and repairs submitted
and the fire alarm is functioning. You agree to pay a finance charge of on this form. All lest procedures were performed in accordance with the latest edition of the Colorado
L5% per or a minimum of $5.00 whichever is more on invoices that are Cross -Connection Manual. I believe the submitted information is true, accurate, & complete. I am aware
Thirty (30) days past due. That there are significant penalties for submitting false information including the possibility
of fines or imprisonment.
OWNER WATER DISTRICT TESTER