HomeMy WebLinkAbout6215 CARMICHAEL ST - SPECIAL INSPECTIONS - 4/29/2006820 Merganser Dr. #406
Fort Collins, CO 80524 970- 91-0006
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Backflow Prevention Device Test & Maintenance Report V
Water Supplier/Au hority:F
Service Name:
Street: 16 a I S 0"ali"J10-
Contact Person: A&M a ✓.0 nJ
Owner/Mgmt. Co./Contractor JQnd
Street: .1-0 5- S n) all
Contact Person: IF
PO: Test No.:
State: Zip:
Phone:-
^ 9%4 377-�ao tR/
-+
Title: Phone: w
Existing: 17 New:y- Replacement For: Permit No. -16 Installed: Horiz. 0 VertZ'�'
USE: Domestic 13 Rre: l] Irrig &nA- , Isolation: tom+ ('.ot*� 0 Process: E3
DeviceType: Reduced Pressure 0 Double check E3 Pressure Vacuum Breaker bJ Oher
Manufacturer: Fin b" Model:-9 6 f Size: .7S- Serial No. #-60AU
Date Installed: caW 0 Last Ins p t' n/Test: Main Line Pressure: %Q PSI
Location on Property: S s e✓
Reduced Pressure Double Check
Pressure Vacuum
Type
Type
Breaker
Re -Test
Leak
Tightness
rin Leak
ens on Tightness ension
Tightness Tension Leak
Leak
Tightness
Te
Sns k n
Air
Inlet
SI
PSI
Check
PSI E T PSI
Leaked
T PSI
Tight
13 eal�d
E3 Leaked
PSI
Check 0 Tight
#2 p Leaked
PSI 0 Tight
13 Leaked PSI
T
Relief
PSI
Valve
PSI
PSI
Buffer
Zone
PSI
PSI
Shut Off Valve No.1 O
Leaked Tight
Shut Off Valve No. 2 0
Leaked ALTight
Device Mechanical Test: Pass Fail 0 If Mechanical Test fails, the water authority must be notified immediately and repairs made as
soon as possible.
Repairs/Comments:
Person notified of any failture:
Title:
Alarm Company/Fire Department Notified:
Turned Off: Date: Time: Turned On: Date:
Time:
Tecnician certifies that this device has been tested in accordance with A.S.S.E. Procedure
Tested by: Lynnette Keim Cert. No. 060-0170 Expires: 1-3-08
Company: All American Backflow Phone. 970-391-0006
Street: 820 Merganser #406 City: Fort Collins State: CO
Test Equipment used: Watts TK/99E Zip: 80524
Last Calibration Date: 3-20-06
Technician: Date:_ 0 Time: f( ` + 5
Device Owner/A nt: Date:
Time:
Keep test form on file for minimum of three years.