HomeMy WebLinkAbout1509 Coral Sea Ct - Special Inspections/Backflow - 06/14/2003BACKFLOW DEVICE TEST REPORT
(970) 352-4735 OR (303) 981-7032 Cell
WTR Dist..Jqmi' n�1 1 l T / ( ', t_ k�
Meter #
No. 4 U 2 Z,5
AJ'S BACKFLOW TESTING.
1540 27`h St.
Greeley, Co 80631
c) 30 6-7
Owner 4 5D? C&4 aX `p C-t--
Service Address l �"i ��j Ca
Mailing Address -1�� !? 6cj f c.)GA
Contact _Z �. t° Title:p 7a)_ I;Z31
RP [j DC [j PVB CONTAINMENT [j ISOLATION [j DOMESTIC [j FIRE [_j IRRIGATION k PROCESS (_J
MFG. %t } S - MDDEL._C i-')MY C-1 I— SIZE. .. SERIAL NO. j i r
LINE PRESSURE. 15� DAT_tINSTALLED. U LAST TEST. NEWExistin
LOCATION- T�.r, r v"�' ,, �l l 1. ra — k' g [�
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight r PSID
TIGHT r IPSID
NO# 2 Tight[ PSID
TIGHT PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dir.of flow L horizontal u () do I
'
TEST DATE: 03 THE TECHNICIAN CERTIFIES /THIS ASSEMBY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS:K FAILED: U TEST KIT:_ 6 Qlel A lc'Yi''%— A5- '{� RE-CALIB DATE: l�ty 1
ADDITIONAL CHARGES:
ALARM CO / FIRE DEPT. NOTIFIED: � / U c
BY WHOM:_
TIME TURNED OFF: %
TIME TURNED ON: A _CONTACT:
CERT #3cia CERT. EXPIRES: ��/C%
I
TESTER: b C i 1 �} jC-j
ACCEPTED BY:
�
TESTER: / _ Tune J , ( Y
Signature
Signature
Singing this report verifies that the isolation valves are in open position
I certify under penalty of law that I have( personally performed the test inspections and repairs submitted
and the fire alarm is functioning. You agree to pay a finance charge of
1.5% per or a minimum of $5.00 which ever is more on invoices that
on this form All test procedures were performed in accordance with the latest edition ofthe Colorado
are
Thirty (30) days past due.
Cross-Comnection Manual. I believe the submitted information is true, accurate, & complete. 1 am aware
That there are significant penalties for submitting false information including the possibility
of fines or imprisonment.
OWNER WATER DISTRICT TESTER
DO NOT REMOVE OR TAMPER WITH THIS TAG
TEST DATE: CERT NO: Zo ,-' AJ'S BACK FLOW TESTING.
TESTED BY:x�i�b� _ 1 � hlfJ j 1540 27Tm St. Greeley, Co 80631
t _f
SERIAL NO: ,j j 8 z7< ( 970) 352-4735 or (303) 981-7032 Cell