HomeMy WebLinkAbout508 KIM DR - SPECIAL INSPECTIONS - 5/19/2003JIM NORRIS �i O aS0
CROSS CONNECTION / BACKFLOW SERVICE PH: 970-229-9287
2326 SILVER OAKS DRIVE '-Q�u
FT. COLLINS, COLORADO 80526 CERT. # 1711
BACKFLOW PREVENTION DEVICE TESTA MAINTENANCE
REPORT
c Water Supplier/Authority: CITY
OF FORT COLLINS
Meter/Account No,
Service Name • ;' i✓ >
of sm use orvy
Street:J�s7Q
City: },.r �Tr,t /��,�
State• C Zip• 0,71
*Contact Person: `:: ` Title: �',�. t�.
-State:
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:OwneHMgmt. Co./Contractor:
;`Street:_v�
State: =' zt .
a Contact Person: ,' 't
Title•
Phone:%�-'
o Existing: ❑ New: Lr
Replacement For:
USE: Domestic: ❑ Fire: ❑
Irrigation: 0 Isolation: ❑ Containment: M.
Device type: Reduced Pressure ❑
Double Check ED Pressure
Vacuum Breakerr191
Manufacture: t '= C r
Model: A, ' Size: /`_Serial
No:
Date Installed: Last Inspection/Test:
a Location on Property:. �`�%! ? = /z - f r= '; he,
Main Line Pressure:PS1
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0
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"a a KEEP TEST -FORM ON FILE
m Device Mechanical Test: Pass •t Fail ❑
Installation: Meets State/Local Standards
FOR MINIMUM OF THREE YEARS
Fails State/Local Standards: ❑
IF TEST FAILS THE WATER PURVEYOR MUST BE NOTIFIED AND REPAIRS XND
REPAIRS MADE
Person notified of any failure: Title:
Alarm Company/Fire Department Notified:
ro
Turned off.
c
c Tested By:
/06
a Company: Phone:
E Street:
o CityState: CZip: 0526
Test Equiptment.used: MID WEST 830 Last Calibration Date: 3/3/03
m` Technician: -'
N big re , - C Time:
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Device Owner or Agent a. 't` �`' ^ Date: r_ / ? !> • Time:
rig -nature
OWNER OR AGENT SIGNATURE INDICATES VERIFICATION BY SIGNER THAT ISOLATION
VALVES ARE IN THE OPEN POSITION AFTER TEST