HomeMy WebLinkAbout602 KEENESBURG CT - SPECIAL INSPECTIONS - 6/30/2004JUL-26-2004 MON 08:06 AM FORT COLLINS UTILITIES
JUL-13-2004 12:3`1� FROM:AFFFORDABLE SPRIWLIN 9703366431
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9704162442
TO:19702216619
BACKFLOW PREVENTION ASSEMBLY TEST AND MAINTENANCE REPORT
Customer must retain a copy of this report for a minimum of three years
Water DisincilAufhoW. Meter/Account No.:__ Test No.:
Service Name:
Service Address: U Z ELw
Contact Person:__-- sI4•A%A Tipe. Phone:
OwnedMgmt co/contracw
Mailing Address:
Contact Person: Title: Phone:
Replbcomant for.
use: containment IsdationZ Domesliic❑ Flre[] InVatloito Process0
Assembly Type: Reduced Pressure ❑ Double Check ❑ Pressure Vacuum Weaker{$ Olher—
Mfg— lit/,Lkws ModeiNo.: '72.& _Size;_�SerialNo,• 6 ell
Date Installed:- Last Inspection: Line Pressure:440_PSI
Location: /_ Ot ris rZ" IV i i40 a sE
Initial Test Results
0
iot .2
Comments
Re -test Results
Check
RP DC. PVe
,
gh
UnOM o
RP. DC
R e
LL:��
'Buffer
R
Air Inlet
Shut-off valve No. t L400 Tom[]
Shut-off valve No.2 Ledo 74hi❑
Repair9/Comments:
P. 01
P.1/1
Assernbiy Mechanical Test: Passed® Falled❑
mart be null N hnrneow and reoeh made a ON a
Alarm Company/Fire Department notification:
Turn OR Date• Time: Turn On Data:_rime•
Technician certlffe:i Ws assembly ha been tad in accordance with ASSE Procedures: 5010-
Tester Name: iv�e., s A a G. Certification No.: L�!
' ..�ExPires� *7—i7 _ S
Tester Signature: Test Date: '')'f .o Trme JL
Tester Phone: Test Gain!' auge R"rt Date: '7 —
Owner or Agent Signature: X
SIOnmun W41=189 vedcaft by Sirrwr that kewftn vmv" waft rNwnsd to pn�tssl o.fsnuson:
Colorado Cross -Connection Control Manual - March 200000 Appendix E - Page 135