HomeMy WebLinkAbout2621 Thoreau Dr - Special Inspections/Backflow - 06/15/2007JUN-19-2007 TUE 02:40 PM
FORT COLLINS UTILITIES
9704162442
P. 04
BACKFLOW DEVICE
TEST REPORT
No.
Al's Baud fKow Testfnq LLC
'Your Cvs-Co fustian Carur':rirm"
l540 2?th SI., Grecle),, CO 80631 • (970) 352-3090 or (303) 981-'.032 Cell
N'rR Dist. �C. iCtks
Meter 9
Owns, ��tx�rrtP� %Ksr�e� 5
5235
Service Address aGO71 e ✓ �.. ak L� o �i1
Mailing Address u►raC P __3:357 &4--e 14%2 �e Cd ff' 2514
Confect �/lRt{ _Title: G41�(g' FOr
—_ I hone: ( �o�) $rj� �j %J7
PP DC pV6 CONTAINMENT❑ ISOLATIONO DOMESTIC❑ FIRE.] IRRIGATION PROCESSI,
MFG. 1 ,�� MODEL _762CI A SIZE 3�L, SERIAL NO. C57 .2h l7 �.7
LINE PRESSURE O DAl'E INSTALLED LAST TEST
I NEW OV Existing ❑
LOCATION Sott;L. < eat Anrr PC p
ltsl UAfE:lde5/6t THETECHNIC[ANCERTIFIESTHISASSF-10BL1'HASBEENTESTEDINACCORD.hNCEN'ITHPROCEDURES
TEST PASS: K FAILED. [I:ASSESDUO TEST KIT; MB%rfr� ��
RE CALIB DATE:
ADDITIONAL CHARGES:
CO VMfE-NTS:
ALARM COIFIRE DEPT NOTIFIED: `_ �,
�/� BY WIiOM:
TIME TURNED OFF: — A TIME TURNED ON: 9A
CERT k CONTACT:
CERT. EXPIRES !O Ice TESTER: AST
N'
ACCEPTED BY:
Sigmturc
Signing this report wriGm that The isolation valszc are it. open pociti;:n
and the fire uhtrtn is functioning. Yitr ugree to pay a (inunee ehttrg< of
L 5'Y per nr a minimum of 35nO wfiicltever is mom on im•uiees'hat nm
Thirty (30) days past due.
TESTER: Time r I
Signature
1 certify undn penalty of lain if have nenenal ly performed the -eat inspcaiens and repairs submittedactihis form. All lest prctttdtrres ..ere performed in accttrdnnce With the latest edition of file Colorado
Crass -Collection Mnnuui. I bulicve the submitted infrrmatiot is nuc, accurutc, & complete. I am aware
That there ar- significant penalties forsubmiCing false information including the possibility
Of fines nr imprisonmcnl.
OWNFR 1lrn rrn
�-d VU999COL6 uosuowig aiuuoe dZb:90 LO 96 unf