HomeMy WebLinkAbout6123 Carmichael St - Special Inspections/Backflow - 05/15/2003BackflowTesting
1235 Carlene Drive a Loveland, CO
DATE OF TEST -
OWNER'S NAME:.
SERVICE ADDRESS:
MAILING ADDRESS:
Services
80537. 667-9874 3oao 157?
BAtCKFLOW PREVENTION DEVICE No. 4956
TEST AND MAINTENANCE REPORT 61�3 �Z/�!xC/�i�FL
DATE OF LAST TEST
TELEPHONE #,
The backflow prevention device detailed below has been tested and maintained as required by the water supplier and is
certified to comply with these rules and regulations. 1 � ?� , t, • e (_.5
LOCATION OF QEVICE: J+1t *�3 ' �" 1A A;. ` CONTACT PERSON: 'N
DEVICE:
anuacturer fype M0001 No. erio. A size
LINE PRESSURE AT TIME OF TEST PSI PRESSURE DROP ACaROSS FIRST CHECK VALVE PSI'
INSTALLATION NEW ,% EXISTING REPLACEMENT FOR DATE
Reduced Pressure Principal Device
Pressure Vacuum Breaker
Double Check Valve Assembly Relief
Air Inlet
Check Valve
1st Check 2nd Check Valve
opened at
psi
Closed Tight ❑
psi
Initial
DC Closed Tight
Closed Tight LA
Opel at
Test
RP-_psid
Leaked ❑
)paid
Leaked ❑
"
Did Not Open ❑
Leaked ❑
Repairs and
Materials Used
After
DC Closed Tight ❑
Closed Tight ❑
Opened at
Opened at
Closed Tight ❑
Repairs
RP -_paid
esid
P
-psi
psi
rH��tu FAILED ❑
t
COMMENTS:-:� it 1 • ;'a,,,
NAME OF PERSON NOTIFIED IF QEVIPE FAILED AND NOT REPAIRED:
WATER PURVEYOR: "*--'- ' (i — C
TESTING COMPANY: Backflow Testing Services TESTER:
ADDRESS: 1235 Carlene Drive CITY Loveland
STATE/ZIP CO 80537
GAUGE TYPE �r ' ' = 4' �� LAST CALIBRATION DATE: "" =? EXPIRATION DATE:
SIGNATURE: ^=�''6� '(_?>"_ °-� ' CERTIFICATION #:[___ DATE: {�
White Copy - Owner YeNow, Copy - Water Ur"ity Tag Copy - Tester