HomeMy WebLinkAbout2620 Ashland Ln - Special Inspections/Backflow - 08/04/2007BACKFLOW DEVICE
TEST REPORT MRAAAQ
A3's Bac �ow fisting LLC
'Ywr Cross -cornett!'. cmnecmoo"
c 1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
WTRDist G.LI�U
Meter #
Owner
Service,
Mailing Address 6/z:t .J - c: ne ry-ss % &ce M Yid e/t Y lC2 e+-po,3 / to
Contact XX-. V Title; Lc;�.r�.r7r o-" Phone: (zK03 $!/- 977%
RP ❑ DC ❑11 PVB I/ CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE, �0^ IRRIGATION �s PROCESS ❑
MFG. jrl t 1 V , 115 MODEL 12A A SIZE .314' SERIAL NO. c-9 16 4-c7 jCh
LINE PRESSURE A, q o DATE INSTALLED Is %e 0 LAST TEST NEWX Existing El
LOCATION /Y r1 h -.t• ka 4fy
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight Oif PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
.f
AIR INLET of PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE: THE TECHNICIAN CERTTIIFIESS THIS ASSEMBLY BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS:X FAILED: El TEST KIT: f%/, (' vPS4 64S RE-CALIB DATE: 57k.`,�i
ADDITIONAL CHARGES:
ALARM CO/FIRE DEPT. NOTIFIED: /1/1 # BY WHOM: /V ff /� A
TIME TURNED OFF:
Nd TIME TURNED ON: � CONTACT:
CERT # /75c; CERT. EXPIRES: �� / J�O % TESTER:
ACCEPTED BY: TESTER: Time
Signature SignaNre
Signing this report verifies that the isolation valves are in open position I certify under penalty of law that 1 have personally performed the test inspections and repairs submitted
and the fire alarm is functioning. You agree to pay a fnara a 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 S5.00 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 are significant penalties for submitting false information including the possibility
of fines or imprisonment.
OWNER WATER DISTRICT TESTER