HomeMy WebLinkAbout4702 PRAIRIE VISTA DR - SPECIAL INSPECTIONS - 3/21/2012Backflo"wTech
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608 Garrison Street
Unit -L
Lakewood, CO 80215
Phone 303-986-4601
Fax 303-763-8201
Assembly Serial # H761270
Test Datefrime 3/21/2012
Gauge Serial # 06101236
10 District Required Into
Tester Certification # 06.00013
Date Certification Expires 6130/2012
Assembly Test Results 2 Pass[DFail
Backflow Prevention Assembiv Test & Maintenance Report Test #: 125297
(Please Pnnf)
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FORT COLLINS/LOVELA nt
Water District/ Authority Account: Contact Person:
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_
FacilityName RESIDENCE Contact Phone #
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FT COLLINS CO 80526 -.-
Service Address: 4702 PRAIRIE VISTA DR...
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Mailing Address: GREENWAY BARB 16265 E. 33RD DR , S-10 AURORA
CO 80011
Owneril Manager o Contractor ❑ Other: Contact Person:
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Company Name/ Title: RESIDENCE Contact Phone #
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Mailing Address: 4702 PRAIRIE RIDGE DR FT COLLINS CO 80526
Make: Febco Model: 765 Size: 1
Type RPZ --I DC V PVB I SVB Air Gap F_AV13 — LOther
Date Installed: Location on Property:
(Only if Applicable - Include Previous SenahV) Orientation Service
Protection
y
Replacement Assembly Inlet. Outlet: Domestic
Containment
4
New Installation ❑ r Vertical Up 1 ❑ Fire
- Isolation
Stolen ❑ I Vertical Down 1 ❑ j Irrigation
Containment
Previous Assembly Serial # ❑ [—_Horizontal — ❑ Other
By Isolation
Line PSI: so- Initial Test Results Repaired: Cleaned:
Re -Test Results
I
Tightness Differential Ck#1 Ck#2 RV Ck#1_ Ck#2 RV,,__
Tightness Differential
Check Valve #1 1 Leak 1 g Ck#1
c Leak
(C01: RPZ,DC,PVB.SVB) vV_ Tight ,dig spring seat-' I other
'.,. p Tight
_
Check Valve #2 ❑ Leak Ck#2
❑ Leak
(Ck#2: RPZ, DC) ❑ Tight disci spring,.., seat, other _....
❑ Tight
!;
Relief Valve RV
11
(RV: RPZ) \ 'diaphram ❑ seaD OthBC
`
i
Buffer Repaired: Cleaned:
(RPZ) Air Inlet o Air Inlet I
lI�
ed
Air Inlet 4.2 Air rnlat
Air hteu PVB.SVB � poppet U tionne(.. I other: . ........
!
Shutoff Valve #1 Leak JI Tight SOV #1 Open Upon ArrivaljdOpen Upon DeparturelJ Backpressure Exists?
Yes! No J
!
Shutoff Valve #2 Leak vI Tight SOV #2 Open Upon Arrival v ppen Upon Departure[*/ Cause:,_-.
Assembly Concerns: Test Procedure: Comments:
(only if applicable)-- --'- -"
t
Incorrect Installation? -..,I ABPA,V ASSE I--- -----
i
Incorrect Use? �_ ..... -. ... _.. __
Turn Off Date: Turn On Date:
Turn Off Time. Turn On Time: _
Alarm Company/Fire Department Notified:
i
Person Notified Contacted By
Z
Turn Off Date/Time: Turn On Datefrime
x Test Gauge Make Midwest Model: 845 Last Calibration Date:
8/12/2011
I hereby certify that the Isolation / Shutoff Valves (S0V#1 and SOV #2) have been returned to the position in which they were found and that the test was done according to the
procedure shown above required by Cie Water District/ Authority shown above, and the test readings are true and accurate to the best of my able ty.
.(Please
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(Please Print).. -
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Testing Company. Backfiow Tech Phone (303)986-4601
12
#. Customer. Name:
Phone #:
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Tester Name: FINKENBINDER, NEAL (Please Print)
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(Tester) _1 (Customer)
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Signature: ' Signature:
( uom,t a Clearly Pr,nted Copy to the Water Purveyor)