HomeMy WebLinkAbout2475 Ashland Ln - Special Inspections/Backflow - 08/04/2007f,
BACKFLOW DEVICE
TEST REPORT
9{7's Bac6Tow T�esiing LLC
^ym , cuss-Conrtea(on Connecion"
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
WTR Dist. 4 d C C )
Meter #
U 5440
Owner Tr-i.r �t t'�f fain"
Service Address aL -4 7.5 F (W1 S if) �^ ,7(L •
Mailing Address f f/o --� c P33,q"7 W e 9- 1 9 for f-r, P r gC)�7C
Contact TA[" Title; &a.w&JA_ ,_a4+>``� Phone: ('��-J ) r7 q A- 9 71%
RP O DC D PVB QK CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATION k PROCESS ❑
MFG. LC)e IIC4 r-S MODEL `%ZO A SIZE SERIAL NO. t�I CsLaG-Gc
LINE PRESSURE r/ 0 DATE INSTALLED 9_�YC27 LASTTEST NEWX Existing❑
LOCATION rllr-i �C(P G9k 1'd_ p
INITIAL TEST
REPAIRS
RE -TEST
NO# 1 Tight PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET :7 v PSID
I
AIR INLET PSID
Shut off valve # 2 Tight
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATEOkka THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WIIT+H, PROCEDURES:_ASSE 5000
TEST PASS:9 FAILED:❑ TEST KIT: RE-CALIB DATE:
ADDITIONAL CHARGES:
CO/FIRE DEPT. NOTIFIED: ftlx BY WHOM:
TIME TURNED OFF: AM TIME TURNED ON: ,//N'j CONTACT: _>R
CERT # 7Gf �. 0 CERT. EXPIRES: _�)-40) TESTER: R 1 //A' a^2S'"tl'
ACCEPTED BY TESTER:
Signamrc - Time Srl{�1'Yj
Signature
:6.&•1- Signing this report verifies that the isolation valves are in open position I certify under penalty of law that I have pemonally performed the test inspections and repairs submitted
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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
% 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
rty (30) days past due. That there are significant penalties for submitting false information including the possibility
of fines or imprisonment.
OWNER WATER DISTRICT TESTER