HomeMy WebLinkAbout2121 Chandler St - Special Inspections/Backflow - 04/29/2006820 Merganser Dr. #406 ' a
Fort Collins, CO 80524 ' , �� 970-391-0006
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Backf low Prevention Device Test & Maintenance Report
Water Supplier/Aut ority:
Service Name:
Street: Girt. P
Contact Person: 14L rJ S
Owner/Mgmt. Co./Contractor S
Street: 4 66 S o� City:
Contact Person:
PO: Test
City:. _�i2'T s/f '�S State: C Zip:_
_ Tiffe: %,GZ y. e/ SC a —19 e r Phone:174 _
Q SA
Title: / --s' Phone:
Existing: 0 New- Replacement For: Permit No. Installed: Horiz. 0 Vert.
USE: Darrestic C3 Fire: 0 IrrigaW0'lK_ Isolation rmerrt 13 Prooess:
DeviceType. Reduced Pressure E3 Double Check 0 PressureVacuum Brea Other.
Manufacturer: �Ce) Model: Size: . % �� Serial No. f toy
Date Installed: . 60 S _ Last Inspe ion/TT t /v Main Line Pressure:7r PSI
Location on Property:C�
Pressure
Double Check
Pressure Vacuum
Re -Test
J1 aReduced
T e
Breaker
Leak
erin
rasion
Leak
Tightness ension
Leak
Tightness Tension
Leak
Tightness
Tension
Air
Inlet
PSI
PSi
Check
PSI
Tight: PSI
Q r PSI
Tight
113 3
Leaked
0 Leaked
PSI
Check Tight
#2
PSI 17 Tight PSI
Ti
Leaked
0 Leaked __
0 Leaked
PSI
Relief
Valve
PSI
PSI
Buffer
Zone
PSI
PSI
Shut Off Valve No.1 0
Leaked 0 Tight
Shut Off ValveNo.2 O
Leaked O Tight
Device Mechanical Test: Pass 0 Fail 13 If Mechanical Test fails, the water authority must be notified immediately and repairs made as
soon as possible.
Repairs/Comments: _ #. wl I/a. ty a iD a liee_
Person notified of any failture:
Title:
Alarm Company/Fire Department Notified:
Turned Off: Date: Time: Turned On: Date: Time:
Tecnician certifies that this device has been tested in accordance with A.S.S.E. Procedure
Tested by: Lynnette Keim Cert. No. 060-0170 Expires: 1-3-08
Company: All American Backflow Phone. 970-391-0006
Street: 820 Merganser #406 City: Fort Collins State: CO Zia: 80524
Test Equip nt u Watts TKI99E Last Calibration Date: 3.20-06
Technician: Date:— ' aZ c!^— Q too Time: 1.11
Device Owner/Agent: Date: Time: I I �
Keep test form on file for minimum of three years.
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