HomeMy WebLinkAbout2632 Thoreau Dr - Special Inspections/Backflow - 06/15/2007JUN-19-2007 TUE 02:43 PM
FORT COLLINS UTILITIES
9704162442
P. 08
BACKFLOW DEVICE
TEST REPORT
Af's Baci)Tow rfestin9 LLC
7w' CYatt •Cm vrrmon G+an:crlan"
1540 27th St., Greeley, CO 80531 • (970) 352-3090 or (3031 991-7032 Cell
R'CR Dist. F4. (f4>1 r—G _
Meter C
No.
5231
Owner �— , f A& �S / ,,,,/
Service Address _ aZ C-3 V ti&lot Eta c � F4, Co J/-r" GO i os.-; _
Mailing Address �t tL cf�e 335 7 erJr2 j <j I& Z--r<" to 6;;� 4599.S/ 6
Conlact _�YI(i1J Title;
RP ❑ DC ❑ PVB CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATION �t PROCESS
MFG. _ /J�i1 i(cf�S MODEL -7--2r, 4 SIZE SERIAL NO. C 171 31S
LINE PRESSURE 80 DATE INSTALLED
NER' Jo Existing ❑
LOCATION C-xxL C_ e- z>C
LAST TEST
INITIAL TEST
REPAIRS
RETEST
NOF I Tight PSID
TIGHT 0PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEFVALVF PSID
BUFFER PSID
BUFFER PSID
AIR INLET 0 PSID
AIR INLET PSID
Shut offvalve K 2 Tighr
Dir. of flow [ horizontal ❑ up ❑ do
TEST DATE :b/�THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURFS:—ASSE 50t10
TEST PASS: P.41LC•D: ❑ T&ST K77': 01 JaI L..2-0G+J5- RE-CALIB DATE:
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED: _ _ /(.LR' BY WHOM: A+
TIME TURNED OFF: ALK TIME TURNED ON: � A CONTACT: a[�
CBRTh �%�I<jp CERT. EXPIRES: ,__f O O!( TESTER: S!A20
ACCEPTED BY: 4!4z,Pfr
Time
SienaNrc TESTER: 4 f Signature
Signing this report verifies that the isolation valve: arc in open posilion I certify indcr penalty of luw that I have mots ally Performed thew inspections and repairs submitted
and the fire alarm is ftmotiorting. Yon agmc to pay a finance charge of on this form. A11 tear procedure: were pulonnod in acconlunce wits the latcst edition of the Colorado
:.5% per or a ninimum of f5.0U whi,:hcv,r is more on hmoices that are CT0SS-Cnnnection Mnnual, f bellow the subrowed information is true, accurate, A complelc. I . swam
Thirty (10) days post cue. That there are significant penalties for submitting 51!se intormation including the possibility
of fines or imprisonment.
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