HomeMy WebLinkAbout6575 ROOKERY RD - SPECIAL INSPECTIONS - 9/23/2004Olson, BACKFLOW PREVENTION ASSEMBLY
IRRIGATION INC. n TEST &MAINTENANCE REPORT
Installation: New:ztisting: permit one:
service Name:
Service Address: ���s�D�e-✓'ate
Mailing Address: Sa m e
city:yv i Cc?��c�5 State: -CC) zip: p• 0_CLSZ8
Contact Person: Title:
Assembly Make: ��t� Model: r� Serial#: � �S Size: �(
Location on Property: c IX S+. Sri 006c.. -ecy
water supplier:
Test Procedure #: 10 (- I
TESTS FOR DOUBLE CHECK7psid
REDUCED PRESSURE ASSEMBLIES
Direction of Flow: Check ails Check #2: =9psid Relief valve:2"�
Leak Tightness: Check 01: Tight :Leak: Check #2: Tight: > Leak:
TEST FOR PRESSURE VACUUM BREAKER
Check Valve: paid Leak Tightness: Tight: Leak: Air Inlet:4
REPAIRS AND COMMENTS
Pass: Fail: Line Pressure:
Repairs: l►� �''�
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Comments:
THIS TESTER CERTIFIES THIS ASSEMBLY MEETS MINIMUM STATE AND LOCAL SPECIFICATIONS
Tested By: tpnr 06vno - Certification #: 1- 3 Expires: ZQQq
Gauge Type: Vjfk4S 'SIG Last Gauge Calibration Date: .p
Date of Test: T f Test: W_--2_VTe3ter Phone Number: (� 78'"3D1S2
Tester Signature: Owner or Agent Signature:
ANNUAL RETEST REQUIRED
WHITE COPY -OWNER YELLOW COPY -WATER UTILITY PINK COPY-TESTEF
P.O. Box 1098 • Wellington, CO 80549 • (970) SN-7052 • (970) 204-5597
ZO 'd ZVVnIVOL6 S3I1111 n SNI1100 1803 WV Pe:60 NOW POH-LZ-ES