HomeMy WebLinkAbout4808 Prairie Vista Dr - Special Inspections/Backflow - 10/03/2012V�)1"L0
BackflowTecl�
610 Garrison Street
Unit - W
Lakewood, CO 80215
Phone 303-986-4601
Fax 303-763-6261
Assembly Test Results
Backflow Prevention Assembly Test & Maintenance Report
/PIAAea Print)
12Pass ® Fail
Test #:126868
Water District/ Authority: FORCOLLINS/LOVELA Account: Contact Person:
Facility Name: HARMONY RIDGE Contact Phone #:
;cA
4 Service Address: 4808 PRAIRIE VISTA DR. FORT COLLINS CO 80526
a.
'(*af Melling Address: GREENWAY BARB SANDOVAL P.O. BOX 110871 AURORA CO 80042
'(Owner❑o Manager ❑ Contractor ❑ Other: Contact Person:.
'91 Company Name/ Title: HARMONY RIDGE Contact Phone #
O Address: 4808 PRAIRIE VISTA DR. FORT COLLINS CO 80526
3Mailing
rl_ 1Make: Febco Model: 765 Size: 1
3 1 Type: ❑ RPZ ❑ DC R) PVB ❑ SVB D Air Gap ❑AVB DOther
Date Installed: Location on Property: SIDE OF HOME o/S
_N.
Ei(Only if Applicable - Include Previous Serial#) Orientation Service Protection
�a❑Replacement Assembly Inlet: outlet: ❑ Domestic W Containment
a- flew Installation ❑ ❑ ❑ Fire q Isolation
❑Stolen ❑ k Vertical Down ❑ o❑ Irrigation U Containment
rlPrevious Assembly Serial # ❑ — Horizontal —• ❑ ❑ Other By Isolation
{Line
PSI: 80 !Initial Test
ResulR
Repaired: Cleaned:
Re -Test
Results
Ti htnes
Differential
Ck#trek#21__1RVo❑ Ck#loRjk#2cDVo❑
rTightnessj
Differential
Check Valve #1µ y r Leaky
D
❑Leak
s �1 5'
it
Ck#1L SHED DEBRIS F ROM 4SSEMBLY 4 f}
r
(Ck#1',RPZ,DC,PVB;SVB)�x�,
`S,t^
disco❑PriYn�goDeatgDther. . s , p,�S r 0.r 9{ N x .i'OTight
Check Valve #2 I ❑ Leak
j
jCk#2
I ❑ Leak
}
(Ck#2 RPZ DC) ❑ Tight
I
�disco ❑pnngoDeatoDther
❑ Tight
-C
� .yrl `. rP a' e
(RV: IRPZ) ''.s-,-r F
Buffer, y
.,'{_
..,,' `ttliaphram
ifi +,cS, i dad-, v 5�1 ✓� � � a� '� 4 a' ,�. � 5�
seat'IDother, '•' "'..-.,"_:.�._....:....>... x ''s..
Repaired: Cleaned:
L �
�iW
r uw
Y-y- T.f
`'.
;(RPZ)
Air Inlet ❑ Au Inleto❑y
Alrrinlets . r
4lrtnlerr
et�other x, n w a) a� ��� E
�e 2
Shutoff Valve #1 Leak
O Tight
bon �.�..:..... y - .,
ISOV #f Open Upon ArdvalODpen Upon Departure. W f Backpressure Exists?
. t;m
Yes
..rr3�..`,1.
❑ No Lt
F
Shutoff Valve #2 ❑ Leak
R❑ Tight—
iS0V#2 Open Upon ArrtvalWppen Upon Departure:
r
Assembly Concerns:'Test Procedure: (Comments:
+y.
(only if applicable)
fI Incorrect Installation? I� 4d fiABPA W)4SSE ❑
1
Incorrect Use ?
Tum Off Date: Tum On Date _
p .Turn
Off Time: Turn On Time:
Alarm Company/Fire Department Notified:
o
y Person Notified: Contacted By:
=Turn
Off Date/Time: Turn On Date/Time:
E
Test Gauge Make:PmMaster Model: ASRP4 Last Calibration Date: 3/15/201z�
e I hereby C@Rdythal the n t isolalloShutoB Valves (SOV#1 and SOV #2)'have been returned to the position in which they were. found and that the test urea Cone aocordm'g to the-
.j rS AH"f
requaed try the Water Distn� s own ve; andtAe test readings are tore anu aaurate td the best of my aDt A ' A ��-
procedure shown'abOve ty ;a � .
(Please Print), (Please Print) .-
Tesbny Company Backflow Tech I W ,, 4 Pho e # (303)986 4601'. Customer,Name =' ' •» Phone# _ ' A^
Tester Name: FWKENBINDER, NEAL (Please Print)
-p� (Customer)
) (Tester)
2C
,i signature: Signature:
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