HomeMy WebLinkAbout4744 Prairie Vista Dr - Special Inspections/Backflow - 10/03/2012610 Garrison Street
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www,Lakewood, CO $0215
-° rt 9Phone 303-986-4601
BackflowTech.com Fax 303-763-8201
Assembly Test Results
Backflow Prevention Assembly Test & Maintenance Report
(Please Plim)
lgllpassOlFail
Test #:126865
Water District/ Authority: - FORT COLLINS/LOVELA Account: Contact Person:
!Facility Name: HARMONY RIDGE Contact Phone #
CService Address: 4744 PRAIRIE VISTA DR. FORT COLLINS CO 80526
_?Mailing Address: GREENWAY BARB SANDOVAL P.O. BOX 110871 AURORA CO 80042
= ;'OwnerO Manager ❑ Contractor ❑ Other: Contact Person:
a-! Company Name/ Title: HARMONY RIDGE Contact Phone # :
° lMailing Address: 4744 PRAIRIE VISTA DR. FORT COLLINS CO 80526
Make: Febco Model: 765 Size: 1
Type: ❑ RPZ' D DC . 0 PVB ElSVB D Air Gap ?: • ❑AVB ❑Other
;Date Installed: Location on Property: N. SIDE of HOME o/s
.a.;
E I(Onry dApplicable- Include Previous Seriaf#) Orientation SONICe Protection
% E]2eplacement Assembly Inlet: Outlet ❑ Domestic 0 Containment
a❑New Installation o t Vertical Up t ❑ ❑ Fire Isolation
❑Stolen ❑ ❑ ❑o Irrigation U Containment
Previous Assembly Serial # ❑ --� Horizontal ❑ ❑Other By Isolation
FLine PSI: 80 ; Initial Test ResultsT~
Repaired: T
_
Cleaned: Re Test Results
Tightness DI erff entiall
Ck#1cDik#2❑RvaD
Ck#1oDk#2rDVc0 rTlghtness�Differential
Check:Valve #1= ❑teak
2
Ck#1 za k 4' �z H £ ..,; _ ' t `
ar '
❑Leak
(Ck#t RPz DC PVB SVB) a e Tight
'� ,�`
disco ❑pnngo❑eato Dther �, � h" ° = :a
❑Tight;,„.
, ;; �, ",. ,,
=. •Check
❑Leak
Valve #2 1 ❑ Leak
I
lCz
(Ck#2 RPZ, DC) ❑ Tight
(disco❑pnngo❑eatoDther
❑ Tight
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draphram seatii7other, w
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Buffer
Repaired: Cleaned:
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(RPZ) it'
Atr Inlet > r
Air Inlet ❑ Air Inleto❑
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Arr Inlet '` " �"...'. F'' ,L 4s--
.,. i-re 3`� 2 6'. �" <yt"
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p L h y u-4' e rnwR �ffyrr ,'+IA^$),{ rw�sew ^• - w
_'.Y M F 5'`AY { F•1 YIbSY i' IN� L f'"Y' A. P-0 .afy % S
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(Fur Inlet PVB SVB),, x4
• • •-.poppet
Shutoff Valve #1 ❑ Leak
Q Tight
!SOV #1 Open Upon ArrivalIV pen Upon Departure: LvfJ) Backpressure Exists? Yes ❑ No U%1
-
#2 Open Upon Arrival WDpen Upon Departure: Cause:
Shutoff Valve #2�D Leak 0 Tight jSOV
'
Assembly Concerns: ;Test Procedure: Comments: ^�
•:,
i
(only if applicable) I�
Incorrect Installation? 4d jABPA 04SSE ❑ l
-
Incorrect Use ?
Turn Off Date: _ Turn On Date:
]Turn
Off Time: Turn On Time:
;Alarm Company/Fire Department Notified:
oPerson Notified: Contacted By:
Z:1Turn Off Date/Time: Turn On Date/Time:
Y Jest Gauge Make:ProMaster Model: ASRPa Last Calibration Date: 3n5/2012
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9 -
1 i 1 heretry cerbty that the IsoWson ! ShutoR Valves (SOV#1 and SOV #2)'have been relumed to the po'sitwn in which they were found antl Uiat the test wasxCdne a mg to the
(' . a procedure showoaDDve required by the Water Drsthctl Authority shoxm above and the test reatlings�are true arid-acairete toDie best of my"abihty �"rt=' ' y'-
' (Please PnM) m f ti 3�1' r-t' + 4` rr�,,r aex.ev''c'zf. ` � �r `_n ` (PIea48 Pant) �,3, ",^•y `T''.�y ¢•*ot .�X I „n '�• it ,,�. , ,..-, v1 :
Tech �� j (303)986.4601 (Customer
Nesting Company.'Backflow •phone # Name u Phone #:,
Tester Name: FINKENBINDER, NEAL_ _ (Please Print)
(Tester) p (Customer)
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(Signature: Zr Signature:
touumu a �rcwry rnmea wpy to me water ruweyor)