HomeMy WebLinkAbout1514 Coral Sea Ct - Special Inspections/Backflow - 06/14/2003BACKFLOW DEVICE TEST REPORT
(970) 352-4735 OR (303) 981-7032 Cell
WTR Dist. t,14 4-
Meter #
NO. 4
AJ'S BACKFLOW TESTING.
1540 27" St.
Greeley, Co 80631
13) 0 3 0 3IS-6
Owner f5� ae_Lc�! �ak � ev—
Service Address ���—C1 / �ew / Cs��, 12�y� �•!�� 1 ,y �r>> ,fit-'
Mailing Address t' 140 1 a--r Jf rt 5 :7,::� 7 t1 S, 6, Ut n ' <-' t I ;-, C ( i
Contact F f t 14 Phone:('-;2t:-) —43
RP [_) DC [j /rPVB [ CONTAINMENT [j ISOLATION [j DOMESTIC U FIRE [j IRRIGATION )d PROCESS [j
MFG. i'� g.r 4S = MOOEL-.L�r°% =`f SIZE. = _- SERIAL NO:._
r
LINE PRESSURE. DATE INSTALLED. _ (��_ LT TEST. NEW K Existing [j
LOCATION- A� n " � _ .n � 1 � . r AST I —
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight 1 Cs PSID
TIGHT PSID
NO# 2 Tight f I PSID
TIGHT PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET(,A-PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dinof flow horizontal u ] do
TEST DATE :-� THE TECHNICIAN CERTIFIES THIS ASSEMBY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS: FAILED: [j TEST KIT: 4C t21a1 40,_ � _4 { RE-CALIB DATE:- r rj1
ADDITIONAL CHARGES:
ALARM CO / FIRE DEPT. NOTIFIED: li
TIME TURNED OFF:_Vt % TIME TURNED ON: kNf _CONTACT: j i
CERT #}
CERT. EXPIRES: TESTER: b
ACCEPTED BY: TESTER: t
Tim Signature
. Signature
Singing this report verifies that the isolation valves are in open position I certify under penalty of law that 1 have personally performed the test inspections and repairs submitted
and the fire alarm is fimctioning. You agree to pay a finance charge of on this form All test procedures were perforated in accordance with the latest edition of the Colorado
1.5% per or a minimum of S5.00 which ever is more on invoices that are Cross -Connection Manual. I believe the submitted information is true, accurate, & complete. I am aware
Thirty (30) days past due. 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
r
TEST DATE: gg4�f� _CERT NO:. ) 5 g AJ'S BACK FLOW TESTING.
TESTED BY: TH
1540 27 St. Greeley, Co 80631
SERIAL NO: f i1(G ( 970) 352-4735 or (303) 981-7032 Cell