HomeMy WebLinkAbout621 Keenesburg Ct - Special Inspections/Backflow - 06/14/2004NOTES:
DATE OF TEST (o / it /
OWNER INFORM A ION
NAME
SERVICE ADDRESS
EXISTING NEW ❑ PERMIT #
BILLING ADDRESS CITY
WATER SUPPLIER
DEVICE INFORMATION
TELEPHONE #
STATE/ZI P
CONTACT PERSON
IRRIGATION ❑ FIRE PROTECTION ❑ BOILER ❑ OTHER
MANUFACTURER MODEL # SERIAL # 4 SIZE "
LOCATION OF DEVICEaF Dr- lit� Q
TEST INFORMATION
X( PRESSURE VACUUM BREAKER
AIR INLET OPENED AT P.S.I.
CHECK VALVE TIGHT AGAINST FLOW ?RYES
❑ REDUCED PRESSURE ASSEMBLY
1 ST CHECK WITH FLOW P.S.I.
RELIEF VALVE OPEN P.S.I.
SUPPLY PRESSURE C P.S.I
CHECK VALVE WITH FLOW P.S.I.
❑ NO
2 ND CHECK TIGHT AGAINST FLOW? ❑ YES ❑ NO
❑ DOUBLE CHECK ASSEMBLY
1 ST CHECK WITH FLOW P.S.I
1 ST CHECK TIGHT AGAINST FLOW ❑YES ❑NO
2 ND CHECK WITH FLOW P.S.I.
2 ND CHECK WITH FLOW P.S.I.
2 ND CHECK TIGHT AGAINST FLOW ❑YES ❑NO
0 PASS ❑ FAIL PERSON NOTIFIED
COMPANY INFORMATION
TESTING COMPANY; FORT COLLINS SPRINKLERS PHONE # 223-5625
ADDRESS P.O. BOX # 2202 CITY FORT COLLINS STATE / ZIP CO 80522
GUAGE TYPE ORANGE RESEARCH (5 VALVE) LAST CALIBRATION DATE 7/ I /
TESTER J,,fta {. FL CERTIFICATION # tW EXPIRATION
SIGNATURE, . ,., / i.
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