HomeMy WebLinkAbout508 KIM DR - SPECIAL INSPECTIONS - 5/13/2003JIM NORRIS
CROSS CONNECTION / BACKFLOW SERVICE PH: 970-229-9287
2326 SILVER OAKS DRIVE
FT. COLLINS, COLORADO 80526 CERT. # 1711
CKFLOW PRFVFNTir)M r) =III r`C TCeT 9 RIA t.rT-
Water Suppller/A thorny:
°Service
CITY OF FORT COLLINS
meter/Account No. .
Name: )•
p if/�
akzwU""
€Street:.SO XZN Ae
City: -01.7 LDG'//_A/
State• L° Zip:
.Phone:
@Contact Person: )c i•
a 1✓ �- Title:_ Dhi v-c �
2,23 - ?'//s
owner/Mgmt. Co./Contractor:
oStreet:-S9•yv_
Contact Person: C{,�/b/
City: 4/e-
State: � Zip:
)
Title:
Phone• 9,9
o Existing: O New: �R
Replacement For:
A USE: Domestic: ❑
€
Fire: ❑ Irrigation: I1 Isolation: ❑ Containment: ❑
Device type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Breaker
Feb
Manufacture: co
m
---Model:- %low Size: /
Serial No: Oo
Hi0 3U1
Date Installed:
e
Last Ins ectionfrest:
, P
Main Line Pressure:�PSI
oLocation on Property:
SoUTj, SIcl- 2A" s hU1,s f
-
c
0
R
E
0
c
A
a
m
It
4d
w KEEP TEST FORM ON FILE
m Device Mechanical Test: Pass 0 Fail ❑
ro Installation: Meets State/Local Standards -04
FOR MINIMUM OF THREE YEARS
Fails State/Local Standards: ❑
IF TEST FAILS THE WATER PURVEYOR MUST BE NOTIFIED AND REPAIRS AND
REPAIRS MADE
Person notified of any failure: Title:
Alarm Company/Fire Department Notified:
° Turned off: Date: Time: Turned on: Date: Time:
R
This Technician Certifies this Device has been tested in accordance with
o the most recent Edition of the Colorado Cross -Connection Control Manual.
c
Tested By: JIM NORRIS Cert. No. 1711 Expires: 11 16/o6
a Company• Phone:
o Street: City:FORT CULLiI43 State. Zip: $0 526
Test Equiptmen used: MID WEST 830 Last Calibration Date: 3/3/03
a Technician: 1 /
m ig ure
te: —l3`- G Time: 1
F' Device Ow er or Ag nt E��
Dates / 3 - 03 Time:
OWNER OR AGENT SIGNATURE INDICATES VERIFICATION BY SIGNER THAT ISOLATION
VALVES ARE IN THE OPEN POSITION AFTER TEST