HomeMy WebLinkAbout2163 Chandler St - Special Inspections/Backflow - 05/27/2004Gc)(-AcD 233Gj
ALPS MECHANICAL N 970-5814317
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Customer must retain a copy of this report for a minimum of three years
Water District/Authority: 4Le_t O gn /(E ZLS 1.0 u aL_-
Service Name: n r I I
Service Address:
Contact Person: �o�,r Title:' drug fr- Phone, 42Y 35��
Owner/Mgmt Co/Contractor:
Mailing Address:
Contact Person:
Title
New ® Existing ❑ Replacement For:
Phone
Use: Domestic ❑ Fire ❑ Irrigation 13
Assembly Type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breaker® Other
Model No.: %� S
Mfg.: �, " Size: Serial Serial No.:
Date Date Installed: S _ Last Inspection: Line Pressure: Sn PSI
Location:
Initial Test Result
Comments
Re -Test Results
Tightness Differential
Tightness Differential
Check No 1
Leak
®
Leak
RP, DC PVB
Tight
Tight
Check No 2
Leak
❑
Leak
ARP, DQ
Tight
Tight
Relief Valve
r��l Tim
Buffer
RP
Air Inlet
PVB
Shut-off valve No.
1 Leak ❑ Tight
Shut-off valve No. 2 Leak ❑ Tight
ASSE TEST USED: 5010-1013-1 5010-1015-2 5010-1020-1 X _ 5010-
Repairs/Comments:
Assembly Mechanical Test: Passed Failed ❑
If mechanical test fails, the Water Purveyor/Authority must be notified immediately and repairs made as soon as possible
Technician certifies this assembly has been tested in accordance with ASSE Procedures
Tester Name: Dennis Alps Certification No.: 1811 Expires: 7/15/04
Tester Signature: Test Date: -5— Oy Time: /Oo
Tester Phone: 970-581-4317 Test Gauge: WATTS TK99E Gauge Re-Cert Date: 5/1/04