HomeMy WebLinkAbout621 Sparrow Pl - Special Inspections/Backflow - 07/26/2012CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
A,�'S Bac �OW '1 �Stl12A LLC
"Your Cross -Connection Connection"
1540 271h Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft9earthlink.ne1
Assembly Serial #:
H C�bocq l62
Test Date/Time:
?- Z(,� f Z 12 , ozPm
Gauge Serial #:
v � �-x; o 0 04
District Required Info:
Tester Certification #:
74So
Date Certification Expires:
Z
Assembly Test Results:
Backflow Prevention Device Test & Maintenance Report
❑ FAIL
F
.. Water DistricVAuthority: C,)frks 9u>`%.<4 Account: Contact Person:
Facility Name: golvr,05 Contact Phone:
Service Address: rrnw P,/ f-4 r A 5- (C7
Mailing Address: 5 G UNF
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company NamefTitle: Contact Phone:
Mailing Address:
Make: Model: ylo s Size: 4/4
Type: ❑ RPZ - ❑ ,DC /(] PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
?" Date Installed: Location on Property: kouse- _
❑ Replacement Device . Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q ?p Vertical Up ❑ ❑ Fire Isolation
J New Installation ❑ Vertical Down ❑ Irrigation El Containment by Isolation
El Stolen ❑ Horizontal 521 ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re test Results:
(�e, d
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
1
Ck#1
❑ Leak
DC, PVB, SVB
1 Tight
` 1
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
iCheck
6jRPZ,
Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
" RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned:
Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
i 4
Air Inlet
!!!of
9 Air Inlet, PVB, SVB
` r
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak
Ti ht
SOV #1 ❑ open Upon Arrival Open At De arture
Backpressure exists? ❑ YES ❑ NO
Cause
' Shutoff Valve #2
1 ❑Leak Ti ht
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure I
Assembly Concerns:
T6st Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
nJ Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # (Z B995
a Person Notified: Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff Valves (SOV # 1 and SOV #2) have been returned to the position in which they were found and that the last test was done according to
the procedure shown above required by the Water Districl/Authority shown above) and the test readings are true and accurate to the best of my ability.
print) AJs Beckflow (please print)
J(please
Testing Company: Testing LLC Phone: 970-352-3090 Cust TheirName: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies o, a Ire line must be registered with the Colorado Division of Fire Safety.