HomeMy WebLinkAbout6127 CARMICHAEL ST - SPECIAL INSPECTIONS - 5/1/2004FROM : FAX NO. : Jun. 30 2004 03:54PM P2
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ALAS MECHANICAL-970-5814317
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Customer must retain a copy of this report for a minimum of three years
Water District/Authority: -Ate- k - -� I l.,�a _..�..__
Service Nam:
less fa .. U- L—;4-S
Service Address: !-g.7
ComactPtrscxi:Ai ti._ Title: vr.,c Phone��L`f- 4
owner/Mgtm ColContractor:
Mailing Address:
Contact Person: _
Title
Newtg ExistingO Replacement For:
Phone
Use: Domestic 0 FireO Irrigation III`
A umbiy Type: Reduced Pressure ❑ Double Check 0 Pressure Vacuum Breaker%
Other
Mfg.: C �� Model �_ Size: � Serial No.:
!- l N_ .ems 712
Date Installed: 5-e5f- Last Inspection; Line Pressures:'- PSI
Location: —v
Initial Test Result
Comments
Re -Test Results
Ti Dit'fererttisl
Ti these Diffetrsttiat
Check No 1
Leak
t.aak
RP DC. PYB
right
Tight
Check No 2
L []
Leak
(RP. DC)
Tight
Tight
RdW Vslve
• . :ti:`
" .
�
'QRiC�Ya,4j1� 1
Ni:
Buffer
a
-ems.
iip:w=
N'
r,
Air IaW
r- : •_
�•r.:...
y ..
p
p��ip
Shm-a 'valve No.
t Leak 0 Tight
Shut-06valve No. 2 Leak [ Tight W
._
ASSE TEST USED: 5010-1013.1 _ s010-10Is-2_- - A 5014-1020-1_X 5010-_--� _
RepairslConunents:
AssevWy Mechanical Test: Pained [' FWW ❑
If mechmi al test fails, the water Purveyor Authority nws4 be notified iarr.eda*-1y and repairs nwk as soon as itossibk.
Technician certifies this sssembly has been tested in accordance with ASSE Procedures
Tester Name: DenniB Ai S Certification No.: j8jl Expires:/j
Tester Signature: Test Date: - /A 'D-:? --4 yr Time: 42
Tester Phone: MSS I-4317 Test Gatsga: WATTS TK99E (3suge Re -Cent Dave: 511/04