HomeMy WebLinkAbout2008 Falcon Ridge Dr - Special Inspections/Backflow - 10/15/2002BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE O
Customer must retain a copy of this report for a minimum of three years-�-, �•�
Water District/Authori ` '
ty Meter/Account No.: Test No.:
Service Name: o v v,,..-,
Service Address: 'ZoD l' /',44 C o ,y ,6 D<e "'' /fir
,
Contact Person: Title:
2 5
Phone:
Owner/Mgmt Co/Contractor:
Mailing Address:
Contact Person: Title: Phone:
New Existing❑
Replacement for:
Use: Containment ❑ Isolations Domestic0 Fire❑ Imgation® ProcessE]
Assembly Type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breaker
Mfg.:— 6e4c2 Model No.: 7l 5�-1 �/ N
Other:
Size; Serial No.
ro
Date Installed:__ f (� �-/-yi-Last Inspection:
Line Pressure:_ _ 5-PSI
Location:_
Initial Test Results Comments
n
Re -test Results
Check No 1 a
L
Leak O
(RP, DC, PVB) 7ightXT
Z• 2-
Ti htness i er ntlal
Leak ,
ec o Leak J
(RP, DC) Ti ht L
Ti ht
Leak :-
Relief Valve
Tight -
Fir—
Inlet
f . . ,. �/. I 4
Shut-off valve No. 1 Leak
Shut-off valve No. 2 LeakF'1
Repairs/Comments:
Assembly Mechanical Test: Passed Failed❑
It me apical test tails the Water Purve or/Autho ' must be notfied immediately and repairs made as soon as possible.
Alarm Company/Fire Department notification:
Turn Off Date: Time: Turn On Date:
Time:
Technician certifies this assembly has en to ted in accordance with ASSE Procedures: 5010-
Tester Name: _ f��i✓E'
Certification No.: !�Expires:_ -i7-y
Tester Signature: � Test Date: /() -iS -�
ZTime:
Tester Phone: S JI Test Gauge: w.4rrs T/t� ,Gauge Re-Cert Date: 7-//- v Z
Owner or Agent Signature: X
Signature indicates verification by Signer that isolation valves were returned to pre -test orientation.
Colorado Cross -Connection Control Manual - March 2000 •.`; ,� c
Appendix E -Page 135