HomeMy WebLinkAbout3223 Muskrat Creek Dr - Special Inspections/Backflow - 07/25/2009JUL-28-2009 TUE 07:44 AM FORT COLLINS UTILITIES 9704162442 P. 04
Water District/ Authority: Account: Contact Person:
04 Facility Name: Con ct Phone #
Service Address: � L Y,\le , F05 o2
_< Mailing Address -
Owner o Manager o Contractor Other- Contact Person: Q Ilt cT
Company Name/ Title: J,-Z M e-f V4 cr C tact Phone #
MailingAddress• 3 / �h
rah da
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Make: jL0 Model: Size:
Y Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ r Gap ❑AVS ❑Other
'-' Date Installed: Lo lion on Property: F,1575 / d f_
W: (Only N Applicable - Include Previous Serial#) Orient -On Service Protection
❑ Replacement Assembly ._L lrilef: Outlet• o Domestic o Containment
aw;_�New Installation Pe fim/ *Nga07v t vertical Up 1 Fire o Isolation
T 0 o
o Stolen o 1 Vertical Down 1❑ ,61Mgation o Containment
Previous Assembly Serial # ❑ —► Horizontal o Other By Isolation
Line PSI:_ i I�j Test Results I Repaired; i Cleaned: ._.1 Re -Test Results
Tlghtnes�Differentlalj Ck#1a rids❑ Ryo ' Ckkin Ca_t_2o RVo___ :Tightness Differential
t'
Check Valve #1 o Leak clr#1 o Leak
.:
(loam: RPZ,DC,PVB,SVB) _ Tight ' t disco spdngo seat❑ other o Tight.
4:;,
Check Valve #2 'o eak Ck#2 --- — a Leak
k->
(Ck#2: ts other RPZ, DC) ❑ Tight i disca spring❑ sear. � o Tight
--- i
--- -----•------- -- _
Relief Valve !Rv + ----
t....
(RV: RPZ) jdiaphrern o seat❑ other_
--- -- --- -
:;
- - --
Buffer -- Repaired: Cleaned: --
�(RPz) Air Inlet o Air Inlets
Air inlet jAirinlet—�—
(ar Inlet PVB,S1/B) _ _ p0( (poppet a bonnet❑ other: ;
'Shutoff Valve #1 ; ❑ Leak lght ! SOV #1 Open Upon Arrival:o Open Upon Departure: a Backpressure Exists? Yes o No�
_ ...-
r ` Shutoff Valve #2 i ❑ Leak _ Tight ISOV #2 Open Upon Anival o Open Upon Departure_❑ Cam:
Assembly Concerns: !Test Procedure: iCo�mrnents:
(only if applicable)
Incorrect Installation? o !'ABPA ❑ ASSE�
,a Incorrect Use ? ❑
=° Turn Off Dater Turn On Date:
f Turn Off Time: Tum On Time:
'`;`Alarm Company/Fire Department Notified:
Person Notified: Contacted By:
z` Tum Off Date/Time: Turn On Date/Time:
Test Gauge Make: If 4!�? Model:KTtk - Last Calibration Oahe:to : /
s I hereby certify that Itte Isolation /Shutoff Valves (SOV91 and SOV #2) have been ratumed to the position in which they were round and that the test area done ecoordinp to the
Procedure shown above required by the water District! Authority shown above; and the lest adinpera true and eoaeate to the best of my ability.
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«;'1Testin Com en :�..RtiJ ��l'I r� �� I ��V C r �•7 � , �, (Please PdrtU
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P Y Phone a# J� r Customer Narne: Phone #
Tester Name: ' I,v.; - (Plea
se Print))
fi
(Tester) (Customer)
Signature: Sionature:
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