HomeMy WebLinkAbout622 S COLLEGE AVE - SPECIAL INSPECTIONS - 7/22/2008Mon ,...... ....,.�/�. _....w 1 --��.. y ...,F ..r -. ..�..r
BACKFLOW DEVICE
TEST REPORT
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6 6307
AJ's Bacq&w resting LLC
"Your Cross -Connection Connection"
1540 27th St., Greeley, CO 80631 • (970) 352-3090 or (303) 9811-/-7032 Cell
WTR Dist. ' C.o�/.z• 5 /3 V F0 V
Meter #
Owner
Service
Mailing Address � >C4tf1C ( r,
Contact A I-�.- f.. -fC��' Title; // d T754' /N r Phone:
RP DC))❑ PVB El CONTAINMENT 1-1ISOLATION❑ DOMESTIC FIRE 11 IRRIGATION ❑ PROCESS ❑
MFG. WaVa 5_ MODEL �.,, �i /NI SIZE / r SERIAL NO. A _-s-56344
LINE PRESSURE O DATE INSTALLED LAST TEST NEW � Existing ❑
LOCATION ct.-F 80 /am o-�-
INITIAL TEST
REPAIRS
RE -TEST
NO# I Tight PSID
TIGHT ❑ PSID
NO# 2 Tight ; p't. oZ PSID
TIGHT ❑ e, PSID
RELIEF VALVE (OPSID
RELIEF VALVE PSID
BUFFER PSID
BUFFER PSID
AIR INLET PSID
AIR INLET PSID
Shut off valve # 2 Tight
Dir. of flow horizontal ❑ up ❑ do
TEST DATE: Zz THE TECHNICIAN CE'RATIFIE THIS ASSEMBLY HAS BEEN TESTED IN ACCORDANCE WITH PROCEDURES:_ASSE 5000
TEST PASS: FAILED: ❑ TEST KIT: /"' '��.57 RE-CALIB DATE:
ADDITIONAL CHARGES:
COMMENTS:
ALARM CO/FIRE DEPT. NOTIFIED:
BY WHOM:
TIME TURNED OFF: A- TIME TURNED ON:--/�/J/A CONTACT: /41T/
CERT# ' ERT. EXPIRES: TESTER:
ACCEPTED BY: TESTER: [// - L Time _2t opm
Signature Signature
Signing this report verifies that the isdlation valves are in open position I certify under penalty of law that I have personally performed the test inspections and repairs 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 edition of the Colorado
1.5 % per or a minimum of $5.00 whichever is more on invoices that are Cross -Connection Manual. I believe the submitted information is true, accurate, & complete. I am aware
Thirty (30) days past due. That there are significant penalties for submitting false information including the possibility
of tines or imprisonment
OWNER WATER DISTRICT TESTER