HomeMy WebLinkAbout2509 Sunbury Ln - Special Inspections/Backflow - 01/24/2014arrea,arore•r�sr,A�a•av�• r�ttas
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Assembly Serial
Test Date/Time: ZI- m
Gauge Serial ff: O5n.-VNMa9
ON I*n COM41*9' I
istrict Required Info:
1A07h58ea0.kiraeby.008=1
r Certification fi; 795b
ofiftW7o.slt3M C2113034111.7002 t4tr9TO356-379A Date
webdW ^I:� 9-%d: siebneeashtisk aer
rtiflCateon F.x i
P res: C
Assembly Test Results: PASS ❑ FAIL
Baakilaw Prevention DeviceTest 8r
Maintenance ffeeRLI 15439
Water District/Authority: e4ca A
uttt•. Contact Person:
Facility Name:
Contact Phone:
Service Address:
Mailing Address:
0 Owner . ❑ Manager ❑ Contactor ❑ Other
Contact Person:
Company Name/retie:
Contact Phone:
Mailing Address:
LU Make: M
9GS Size: �/4 . .
. . ..
it Cap ❑ AVS ❑ Other Device
Type: ❑ RPZ C] DC �VB ❑ SVB 0
Date Installed: Location on P
n SeCyle.0 Protection
❑ Replacement Device Oriente
pvvibw dsvkw mrW Inlet:
outlet 13 Dornoadc p Coritelnrnerd
. Varr"
New In to k*m O Vardow 0
❑ Sedate ❑ Horizon
p ❑ i7 RM
Vffi E3 o Irrlgatkm ❑ ConlsMmer+t by leohftn
d 10 ❑ Ckfrar:
line PISI:
Initial Test Results:
Cleaned:
Re -test Results:
Ck
DRV
0 C"i 0 CO2 ❑ RV
tness DHTArerttial
Ti htness Difteren6Check
Valve 01
❑ Luk
)r4
7FRepalred:
❑seat D othw
Nm
❑o`ear`Check
Valve #2
Wz DC .
❑ t
Q -
❑ ❑other
❑ Leak
p Tigift
Relief Valve
RV
. ay. RP2
:.
❑
Clem ❑ other
Buller Repaired: Cleaned:
RPZ.. ❑ Air irAm - ❑ Air Inlet
Air Inlet Air Inlet
Air hdat, PVe, sys l t g ❑ obormat ❑ ovier
V 1 ❑ U Anivel ❑ Open At ure ®dsW D YES D NO
t:tolf Valve 02. ❑ Laak & W #2 ❑ U R ❑ At 4 Cause
At3sembly Concerns: Test Procedure: ments:
aPP)
❑ Ineorrw Irtctaasdfoe ❑ ASPA m ASSE
❑, h=rred Use
Tfm off date: 1tim on Oats:
17um off tins: Tim on time:
Alarm Company/Fire Department Notified: Fire ailIppreseion Contractor cerf3Ncation #
Person Notified' 1 Contacted by:
Tun off date/Nme.. Turn on datePome:
Test Kit Make: Mld-West Model: INS Last Calibration Date: ->3
) horaby oer* awf the 1o0&*W6lrtrmfi MWE (SOV ar and SOV 04 nave t
Dw pmcsdrsa sham abae requWd by dw faint DftirtMuft
(CAMe prw) AJS BeCkNOW
Testing Company: resdny LLC Phone: e704624M
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Tester Name: AJ Slmon&W Tester Signature:
L00/l00'd Lb4LN UNIMI NCO JAUS f V
d re the poslti n inarhth fmy sera Awns &V stet tea /der fsbr tree caw a000 *V )o
Dow) and are Bost reaaow we fnu and aeanaw Ao rrw best of my aoeay
(Please W"
ir Name: Phone:
Custorm Signature. . . . .
tat be registered with the Colorado Division of Fire Safety
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