HomeMy WebLinkAbout2651 Clarion Ln - Special Inspections/Backflow - 06/26/200846
TEST REPORT 1W. 6208
gys Ba*ow T stung LLC
'TourCrou-Connection Connection'
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
WTR Dist GD
Meter # _
Owner
Service Address S/! zi r : Gn /n f `�, /; //, " S
Mailing Address ti35 % %.tit /Z
Contact _s{tCe / Title; �i.>�I�"e_ Phone:( yC:� )—�'`>�- `� 777
RP ❑ DC ❑ PVB CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATIONS PROCESS ❑
MFG. �U' % k' "tti MODEL 2.;1t
LINE PRESSURE DATE INSTALLED
LOCATION
p SIZE SERIALNO.
LAST TEST
NEW,9 Existing ❑
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight 99 7, U PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET 1. PSID
AIR INLET PSID
Shut off valve # 2 Tight J6
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE: (n/?C^/010THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS: FAILED:❑ TEST KIT: 1+Iy,'4 5�"ft RE-CALIB DATE:
F.1191110Ib)IF41IK61MAtt13 :&A
1K6)blUV1QJ1l.4
ALARM CO/FIRE DEPT. NOTIFIED: h/ M BY WHOM:
a
TIME TURNED OFF: %_ _ TIME TURNED ON:
CERT # !`1 S U CERT. EXPIRES: /1 t J✓ IO 'l TESTER
ACCEPTED BY: TESTER:
Signature
CONTACT: _
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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. I am aware
Thirty (30) days past due. That there are significant penalties for submitting false information including the possibility
of fines or imprisonment.
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