HomeMy WebLinkAbout2503 Ashland Ln - Special Inspections/Backflow - 08/04/2007BACKFLOW DEVICE
TEST REPORT
WTR Dist. i?1rO
Meter #
Owner
Service Address
AJ's Bac qow fisting LLC
'Twr cross-Cm,namatt Connection,
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
rt o`--#, Cn//,')^
10 5441
Mailing Address e-�7.,,(zlyncl-G rCP mysj -7 4, r— ie 14Yo fl, e rcG pep, "
Contact SheA A/ Title; �cs= sOF'�' Phone: ( �KU.N) S �- 9 77-7
RP ❑ DC ❑ PVB IA" CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATION K PROCESS ❑
MFG. `df l �- MODEL 7--ein A SIZE SERIAL NO. 6 1 .70 715 (--
LINE PRESSURE f�� DATE INSTALLED A Aai LAST TEST NEW AC Existing ❑
LOCATION 0-(AQ_5e
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight 5r _,'i IPSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER? PSID
BUFFER PSID
AIR INLET . 62 PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE:,,L2f;i THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS: Ip� FAILED: ❑ TEST KIT: 1)1-*J- (..J —) �] 4's RE-CALIB DATE: i5lr/e
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED
e
BY WHOM:n
TIME TURNED OFF: ,� f A
TIME TURNED ON: (I CONTACT: 14f7r.f
A
CERT # -7i 56 CURT. EXPIRES: _ /1 %�� TESTER: A S .5!NC�i•%�bi✓
ACCEPTED BY: /
Signature
TESTER: GY c -- - - Time ,'4i Yti er
Signature
Signing this report verifies that the isolation valves are in open position
1 certify order 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. I believe the submitted information is true, accurate, & complete. I am aware
Thirty (30) days past due.
That there we significant penalties for submitting false information including the possibility
of fines or imprisonment.
OWNER
WATER DISTRICT TESTER