HomeMy WebLinkAbout1920 Mainsail Dr - Special Inspections/Backflow - 05/21/2003JIM NORRIS
CROSS CONNECTION / 13ACKFLOW SERVICE PH: S70-22S-8287
2326 .SILVER OAKS DRIVE`
FT. COLLINS, COLORADO $0526 CERT. S 1711 0 3
Service uSpp
Nam_o - VC -AA- Meter! w
/11.6 2A Wod4r-4 Oti(�fr�nt No.
V
�Streelrr .�a � i✓_4esL DP City:
�f11�t2CIf;,S�et ,�'n�L sett
City: f f7f�,.:�..�, State: co Zip.
—*Contact Person: Title: Phone:
tOwnedMffsmlt. COJContractor:
Street: U. i3.�-yc I,z76 city: _ 1-7 F cL� i �,s c
State:= 23 Gf 2_
Contact Pernow- R,0-Ad Phone:
Ong: ❑ New: @l Replacement For.
USE: Domestic: ❑ Fire: ❑ Irrigation: 1. Isolation: ❑ Containment: ❑
Device type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breaker
q Manufacture: _ /C eh r ') Model• _ �-�
Data installed- She: -=Serial No• !.2 d
Last Inspectio crest; Main Line Pressure:f5' Psi
$L.ocation on Property: E� Sid ,,.,c' 7ri y,,P
S J J
zLa&L�; M
4p'e ►Mj
G
11 ;m"
00111
j KEEP TEST FORM ON
eDevice Mechanical Test: Pass Eg Fail ❑
e Installation: Meets Statakocal Standards
e
FILE FOR MINIMUM OF THREE YEARS
0- Fails State/Lnca1 St2ndsr.44R- M
IF TEST FAILS THE WATER PURVEYOR MUST BE NOTIFIED AND REPAIRS -AND
REPAIRS MADE
Person notified of any failure: Title:
c Alarm Company/Fire Department Notified:
Turned off: Date: 'rime; Tumed on: Date: Time:
This
the n�ostT� Edition or c4otonaoh crou.coWa, cdin " aiY 1.
e
e Tasted By: JIM NORRIS Cert. No. 1711 . 11 6/06
Company- Expire s.
street. Phone:
City: sbte• a0 zip: o
y Test Equiptrnen . MID WEST 830 Last Calibration Oats: 3/3/03
s Technician:
' o d
Device r or Agen
� Date: Time: