HomeMy WebLinkAbout2509 Clarion Ln - Special Inspections/Backflow - 08/20/2008BACKFLOW DEVICE
TEST REPORTt,.�'�
N�6391
Aq's Bac6q�w besting LLC
"Your Cross -Connection Connection"
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 981-7032 Cell
WTR Dist.
Meter #
Owner •JC1r tflJtN f/!ai'YPF'r7
Service Address rr2 C7 ,/+[r �4-: 7�" r! t� "7 • r C /� %t S F'/7%C.� _.Y�'
Mailing Address A'1CX_L£' (4irC e 3ZH!3 % (�%C c'� /� %R�' �r', e' rp 007 % •
Contact S A• . Title; //z">�ic'e'i f%'`'''� Phone: (_zyo 3 `7 % 77
i
RP ❑ DC ❑ PVB M' CONTAINMENT ❑ ISOLATION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATION b7^ PROCESS ❑
MFG. /,% r /M t ' 3 5 MODEL �t 7t7 SIZE xle SERIAL NO. /.y`f ��"�
LINE PRESSURE' S5� DATEINSTALLED LAST TEST NEW Existing ❑
LOCATION - r 5r cle P
INITIAL TEST
REPAIRS
RE -TEST
NO# 1 Tight ,.,9t y PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET . PSID
AIR INLET PSID
Shut off valve # 2 Tight/
Dir. of flow ❑ horizontal ❑ up ❑ do
TEST DATE: 9✓"' &1 THE TECHNICIAN CERTIFIES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
S❑ TEST PASFAILED: TEST KIT: / J� C/ e'-0--'54 EdA� RE-CALIB DATE:
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED: I)q BY WHOM: /il'4
TIME TURNED OFF: 11.4 TIME TURNED ON: ,& A CONTACT: AA
CERT # 7e/7U CERT. EXPIRES: f//_��'.�'t'il TESTER: ]±i' _1�%J°�t7/t-%`�'e%'/'(/
,
ACCEPTED BY: TESTER: C/C ,�. Time
Signature i Signature
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
OWNER WATER DISTRICT TESTER