HomeMy WebLinkAbout2639 Ashland Ln - Special Inspections/Backflow - 02/27/2008BACKFLOW DEVICE
TEST REPORT
WTR Dist. f_ / C
Meter #
Owner
4#
93's Bacgiow Testing LLC
"Your Cross -Connection Connection"
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
VA 5821
Service Address >e c� M 5 /1 Y' -ir 1 ! n �,!"7 r 0 11 t -% I'r+� Y"'S�'.� 7 r d —1
Mailing Address O�!
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Contact :..gha t -f Title; &14JE� e-u 0' 'e- Phone:( 303 3) `ri 7
RP ❑ DC ❑ PVB CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRES❑ IRRIGATION 2' PROCESS ❑
MFG, /`•-P��r MODEL SIZE ''��� SERIAL NO. f"� ✓�j`t��S^
LINE PRESSURE,^ ��/� c^ DATEINSTALLED �7< 1•" Elk LAST TEST NEW F' Existing
LOCATION r3 °fix. _.7rr rG% e_4 AaC') < e4:1
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 b .O PSID
AIR INLET PSID
Shut off valve # 2 Tight 'j
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE:4� 71t6?THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS: (-j1 FAILED: El TEST KIT: .��1, %� LL.r7 S ' r`�"1�"�j RE-CALIB DATE: �? �6 0ADDITIC L CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED: >� ` BY WHOM: &,14
TIME TURNED OFF: 1I%� , TIME TURNED ON: �j &4 CONTACT: Al 14
CERT # /77t. CERT. EXPIRES: .�1�� TESTER: pp
ACCEPTED BY: TESTER: f / ' __ Time e; !dorya l
Signature Signature f
Signing this report verifies that the isolation valves are in open position I certify under 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. 1 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