HomeMy WebLinkAbout400 Jackson St - Special Inspections/Backflow - 12/09/2010DEC-18-2010 22:42 From:
12/16/2010 18:43 97022GIO79
To:2246134
FARBER LAWN SERVICE
Page:2,2
PAGE 01/01
MICHAEL RUSNAK (HOMEOWNER)
Test Date/Time:
Guage Serial *
District Required Info:
Tester Certification #: 1723
pate Certification Expries:
Assembly Test Results: U PASS LJ FAIL
S cicflow Prevention Device Test & Maintenance Report
1-1-Aeo ndnr and mihmit rmmnfeted mnv within 10 devs of the test)
-Water District/Authority: Ctry o t F t olIins Account: Contact Person:
Facilfty Name: Contact Phone:
Service Address: 400 JAC SON STREET FT COLLINS, S CO 80521
Mailing Address: Same at3 above
Owner ❑ Manager Conhadar tither ontaCtPerson: JOE SULLIVAN
Company Namefiitle: ARCHER HOMES Contact Phone: 227-7588
-Mailing Address: 4020 BINGHAM HILL ROAD FT COLLINS, CO 80521
-Make: FEBCO o e: 7 5 rze-
_.•, Type: ❑ RPZ ❑ DC PVB El ❑ t�p ❑ AVG ❑ Other Device
Date Installed: 12/M010 Location on Property. South Side of House
❑ taa�n�n p�„ t� Orientation Service rotectiop.
"pueviousdevice sa"# Inlet Outlet: ❑ Domestic ❑ containment,
❑ Vertical up ❑ ❑ Fire ❑ I9olatlon
New Insta►latim ❑ Vertical Down ❑ O Irrigation Containment by Iso121ion
❑ Stolen ❑ Horizontal ✓❑ ❑ Other
Line PSI:
Initial Test Results,
Repaired: eaned:
❑ ck*l ❑ Ck#2 ❑ RV jOckat ❑ at,#2 ❑ Rv
e4"t Results
40#
Ti htness Differential
Ti htness Differential
Check Valve #1
RPZ, Dc, PVe SVB
Leak
R right 1.8
t/t#f
❑ Oise ❑ riny ❑seat ❑ other:
❑ Leak
❑ Tight
_ Check Valve 92
❑ Leak
Ck#2
❑ Leak
RPZ, OC
Tight
El disc Elsprf seat El other-
t
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ omer.
Buffer
epaired: Cleaned:
RPZ
❑ Air Inlet Q Air Inlet
Air Inlet
Air inlet, PV8, SV8
2.8
Air Inlet
1 ❑ DoDDet Obonnet ❑ other;
Shutoff Valve #1
Leak
Ti tit
50V #1: O n u Artivat 0 n at Departure
Beckpress�re exists? YES tip
cause
Shutoff Valve #2
1 El leak
Tight
SOV #2:U open uaon Arrival U Opm At Departure
•;Assembly Concerns
Test Procedure:
Comments:
eZ (only if applicable)
'. ❑ InoNred InSmllation
❑ ABPA p ASSE
�❑ Inconea Use
Tum off date:
Tum off date:
I `Tum off time:
ITUM oft t1m2:
Alarm ompany ire Department Notified:
In
Person Notified: Contacted by:
EW Turn off date/time: Turn on dateltime:
est a t e:: Watts Model: TK99E Last Calibration Daw 01/142010
i hereby wo y mat the iso @swb&u off VaMes (SO V e1 and sov a2) Aare bm renrme0 b ure POWW In wnrcn they name fWad and mar the rest teat wee cone sctmwv to
- rAd prooedumA dio" Above r Woad byte Water Dlsfict/Au1R*V &W rA &boar) MOM teat i-7dfiga are hue and Wcw= CD Me bat Of aW NY-
�` (pkam pdno (p(ees® pfou
Testing Company: Farber Lawn SVC Phone 308-5031 Customer Name: MICHAEL RUSNAK Phone
WOWsa Pori()
Tester Name: Mark FartJer Tester Signature: /%% a. vstorner&anmre:
tiaCKnow s are who tesTor repair assemblics on a fire line Must Do MqLstereO YAtI1 the o ore o ivision o ire a e .