HomeMy WebLinkAbout2602 Thoreau Dr - Special Inspections/Backflow - 06/07/2007 (2)BACKFLOW DEVICE
TEST REPORT
A3's Bac(zf�ow besting LLC
'Your Cross -Connection Connection'
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
WTR Dist. 60f. f n11'ri!5
Meter #
Owner ./C.kil-ot cl .11e�m
0
5174
Service Address ...r�Gt7„2. :7 %hnr mr. J b /' ��- f r7h 'C lCJ i�Jl
Mailing Address +'-'�irr%un.f,�xrr_ v. 357 /.m/GX 1'9fV0
Contact .Sla i/6y",? Title; Phone:(
RP ❑ DC ❑ PVB 19' CONTAINMENT ❑ ISOLATfION ❑ DOMESTIC ❑ FIRE ❑ iRRIGATION.K PROCESS ❑
MFG. ��( i r ! let M r MODEL %,Orl 0 SIZE SERIAL NO.
LINE PRESSURE `7 DATE INSTALLED 7 LAST TEST NEW V Existing ❑
LOCATION
INITIAL TEST
REPAIRS
RE -TEST
NO# I Ti *ht _,a PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE: `o/17/r-)7 THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS FAILED: ❑ TEST KIT: /17.r�6c-ta �i� RE-CALIB DATE:
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED: /V9 BY WHOM: ,L/,4
TIME TURNED OFF: 41d TIME TURNED ON: .A/11 CONTACT:
CERT # %C CERT. EXPIRES: /J %'CJ'e- 4 TESTER: 6%.T s/nr CSN.S.nA�
c
ACCEPTED BY: TESTER: Time ? i ✓•-�_
Signature Signature
Signing this report verifies that the isolation valves are in open position I certify Linder penalty of law that I 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 test procedures were performed in accordance with the latest edition of the Colorado
1.5% per or a minimum of $5.00 whichever is more on invoices that are Cross -Connection Manual. 1 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