HomeMy WebLinkAbout2432 Ballard Ln - Special Inspections/Backflow - 11/30/2009BACKFLOW DEVICE
TEST REPORT
WTR Dist t G
Meter #
Owner J`vvr p p 1
Aj's Bac�Tow fisting LLC
You C s Can ction Connectua
1540 27th St Greeley CO 80631 (970) 352 3090 or (303) 981 7032 Cell
i/
,q 7767
Service Address 3� J G c� Zn r-1 '-0
Mailing Address �ffI / UvyK (P -33 5 7 cter,e i 4% / e, P U g U S G
Contact Title Phone ( 3C,3) 55/ S777
RP ❑ DC ❑ PVB r% CONTAINMENT ❑ ISOLATIION ❑ DOMESTIC ❑ FIRE ❑ IRRIGATION K PROCESS ❑
MFG r eb/o MODEL 5 SIZE 31 SERIAL NO
LINE PRESSURE LZ 5 DATE INSTALLED LAST TEST NEW L1 Existing ❑
LOCATION cti 5,cle ar
INITIAL TEST
REPAIRS
RE TEST
NO# 1 Tight W Ji % PSID
TIGHT ❑ PSID
NO# 2 Tight ❑ PSID
TIGHT ❑ PSID
RELIEF VALVE PSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
,/
ry AIR INLET I, PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dir of flow ❑ horizontal ❑ up ❑ do
TEST DATE I/j`�� THE TECHNICIAN CERTIFIEES THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES _ASSE 5000
TEST PASS 0 FAILED ❑ TEST KIT a 1-3 4 5 RE CALIB DATE S�/U
ADDITIONAL CHARGES
COMMENTS
ALARM CO/FIRE DEPT NOTIFIED A14 BY WHOM _4Z !"
TIME TURNED OFF TIME TURNED ON A/ A CONTACT /yA
CERT# 7C/ SU CERT EXPIRES l 0 G TESTER S //nU.vSd,4/
ACCEPTED BY TESTER Time 11 .4Z A",x
Signature Signature
Signing this repo t verifies that the isolation valves are n open posit on I cert fy under penalty of law that I have personally performed the test inspections and repa rs submitted
and the fire alarm is functioning You agree to pay a finance charge of on this form All test procedures were performed in accordance with the latest ed tion of the Colorado
1 5 / ne or a minimum of $5 00 whichever is more on invoices that are Cross Connection Manual I believe the submitted mformaho is true accurate & complete 1 am aware