HomeMy WebLinkAbout514 Kim Dr - Special Inspections/Backflow - 05/19/2003JIM NORRIS
CROSS CONNECTION / BACKFLOW SERVICE
2326 SILVER OAKS DRIVE
FT. COLLINS, COLORADO $0526
Water
Service
Street:
Contact Person
k Ownef/Mgmt. Co./Contractor:
PH: 970-229-9287 930 30 -709r
CERT. # 1711
CAIAK14-C or_nno--
Meter/Accoun
om.wus.nt No.
City: State: Zip:
Title: pt,A.,o•
;Street:.'- t City: State: Zip:
0Contact Person: Title: Phone:
o Existing: 0 New:O Replacement For:
A USE: Domestic: ❑ Fire: C1 Irrigation: Isolation: ❑ Containment: L�
1 Device type: Reduced Pressure ❑ Double Check L7 Pressure Vacuum Breaker i
m Manufacture:
Model• Size: Serial No: 4
3 Date Installed: • "
Last Inspection/Test: Main Line Pressure: ' PSi
QLocation on Property: ,
c
a
M
Q.
m
a
.d
(aKEEP TEST FORM ON
Device Mechanical Test: pass P Fail
Installation: Meets State/Local Standards
FILE FOR MINIMUM OF THREE YEARS
Fails State/Local Standards: Cl
IF TEST FAILS THE WATER PURVEYOR MUST HE NOTIFIED AND REPAIRS AND
REPAIRS MADE
Person notified of any failure: Title:
c Alarm Company/Fire Department Notified:
Turned off: Date: Time: Turned on: Date: Time:
m
This Technician Certifies this Device has been tested in accordance with
1.02 the most recent Edition of the Colorado Crass -Connection Control Manual.
C
Tested By: JIM NORRIS Cert. No. 1711 Expires:to 11 16/06
c Companv: Phone:
E Street:
o Clty: State: C: Zip: O 5 6
Test Equiptment used: MID WEST 830 Last Calibration Date: 3/3/03
Technician:
te: Time:
Device Owner or Agent Signature
Date: Time
i4nature
OWNER OR AGENT SIGNATURE INDICATES VERIFICATION BY SIGNER THAT ISOLATION
VALVES ARE IN THE OPEN POSITION AFTER TEST