HomeMy WebLinkAbout1208 Bateleur Ln - Special Inspections/Backflow - 06/25/2014P.O. Box 2202
Fort Collins, Colorado 80522
(970)223-5625
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Customer must retain a copy of this report for a minimum of three years
Water District/Authority: ' L Meter/Account No.: Test No.:
Service Name: V` kl:i:iA b Y Fi 6-
Service Address: "P)nT6 L C U R 1,N.
Contact Person: Title: Phone•
Owner/Mgmt Co/Contractor:
Mailing Address:
Contact Person: Title: Phone`
New'o Existing ❑
Replacement For: B i 3nL57 S 3 2
Use: Containment ❑ Isolation A Domestic ❑ Fire ❑ Irrigation.& Process ❑
Assembly Type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breakep Other:
Mfg.: I L.h /&:S 5 Model No.: 72-C24 Size: Serial No.• 153 q- 5
Date Installed: _ Last Inspection: Line Pressure: PSI
Location: tj J VL-M 9 t n i tJ i H 13y-5`
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 8
RP, DC
Tight
B
Tight
Relief Valve
RP
Buffer
Q�
RP
i'to. ��.a',iM.
., . "
Air Inlet"
�•L
PVB
Shutoff valve No. 1 Leak ❑ Tight 0
°
Shutoff valve No.2 Leak rj Tight
Repairs/Comments:
Assembly Mechanical Test: Passed M Failed LJ
If mechanical test fails, the Water Purveyor/Authority must be notified immediately and repairs made as soon as possible.
Alarm Company/Fire Department notification:
Turn Off Date: Time: Turn On Date: Time:
Technician certifies this assembly has been tested in accordance with ASSE Procedures: 5010-
Tester Name:
Tester Signature:
Tester Phone:
Owner or Agent Signature: