HomeMy WebLinkAbout514 Kim Dr - Special Inspections/Backflow - 05/13/2003JIM NORRIS
CROSS CONNECTION / BACKFLOW SERVICE PH: 970-229-9287
2326 SILVER OAKS DRIVE
FT. COLLINS, COLORADO 80526 CERT. # 1711
r Water Supplier/Authority: CITY OF FORT COLLINS Meter/Account No. ,
Service Name: XA T v afro use use orgy
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Street: ty: State: ed zip: BoSas
Contact Person: A v Phone:
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Contact Person: Title: •Phone•
o` Existing: ❑ New: Replacement For:
€USE: Domestic: ❑ Fire: 0 Irrigation: ta Isolation: ❑ Containment: ❑
Device type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breaker
Manufacture: /-'-eb co Model: %c1 S Size: l'-Serial No: # OO U
Date Installed: Last Inspection/Test: Main Line Pressure.
Location on Property: So il 7,4 S12 r o —' Th-e A/e Ps-
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Y1 KEEP TEST FORM ON FILE FOR MINIMUM OF THREE YEARS
Device Mechanical Test: Pass Fail ❑
o Installation: Meets State/Local Standards
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Fails State/Local Standards: ❑
IF TEST FAILS THE WATER PURVEYOR MUST BE NOTIFIED AND REPAIRS AND
REPAIRS MADE
Person notified of any failure: Title:
Alarm Company/Fire Department Notified:
° Turned off: -
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Tested By:_
Date: Time: Turned on: Date: Time:
tthhe mTechnician
st r Ic nt Edition of the Colorado hasbeen
Control Manual.
JIM NORRIS Cert. No. 1711 FYnirac• 11 16/06
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Test Equiptmen ^ sed: MID WEST 830 Last Calibration Date: 3
Technician: np
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no or Agent Date: Time:
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OWNER OR AGENT SIGNA URE INDICATES VERIFICATION BY SIGNER THAT ISOLATION
VALVES ARE IN THE OPEN POSITION AFTER TEST