HomeMy WebLinkAbout2215 Dolan St - Special Inspections/Backflow - 04/29/20060sZ1
FortMerganser Dr. #406 9%Q-391-0006
Fort Collins, CO 80524 �'�
Backflow Prevention Device Test & Maintenance Report t4c& Al4
Water Supplier/Authority: r
Service Name: en Le -
Street: o2.7 1 a 1 s ry S¢'
Contact Person: A IQ A) A U(5 "1 S
Owner/Mgmt. Co./Contractor :,k_g"cd EIS'
Street: �Zb City:
Contact Person:
PO: Test No. -
Ed to I I AJZ State:_ C Zip: WD SaaO-
Title: A Q r, D� Phone:
State Zip:
Title: Phone:
Existing: 0 New:-- Replacement For: Permit No. S Installed: Horiz. 0 Vert.
USE: Domestic 13 Fire. a krigation• Isolation: 13 Process: 0
Devic eType: Reduced Pressure 0 Double Check 0 Pressure Vacuum Breaker Clow. /
Manufacturer. � .bC Model: Size: 0 %S 11 Serial No. / /Q % 66
Date Installed: Last Insp tion/Test: Main Line Pressure: PSI
Location on Property: 4 >r
Reduced Pressure
Type
Double Check
Type
Pressure Vacuum
Breaker
Re -Test
Leak
Tightness
Spring Leak Spring
Tension Tightness Tension
Leak Spring
Tightness Tension
Leak
Tightness
Spring
Tension
Air
Inlet
PSI
PSI
Check
PSI G Tight
PSI Leaked
� PSI
Leaked
T
PSI
Check O TigM
#2
PSI O Tight PSI
T
Leaked
El Leaked
0
PSI
Relief
Valve
PSI
PSI
Buffer
Zone
PSI
PSI
Shut Off Valve No 1 O
Leaked O Tight
Shut Off ValveNo.2 O
Leaked [3 Tight
Device Mechanical Test: Pass
soon as possible.
Repairs/Comments:
Person notified of any failture:
Fail 0 If Mechanical Test fails, the water authority must be notified immediately and repairs made as
Title:
Alarm Company/Fire Department Notified: A i%
Tumed 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 men us Watts TK/99E Last Calibration Date: 3-20-06
Technician: Date: A In — 6 Time:
Device Owner/Ag nt: Date: Time:
Keep test form on file for minimum of three years.
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