HomeMy WebLinkAbout505 Coyote Trail Dr - Special Inspections/Backflow - 09/06/2012CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
A J's Bac �OW fisting LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackilowtesting.com E-mail: ajsbftCs'earthlink.net
Assembly Serial #:
H & 6 & 17 6
Test DatelTime:
9-&-17 /oldlrAr^
Gauge Serial #:
05n5oecf
District Required Info:
Tester Certification #:
7550
Date Certification Expires:
fl-M-1Z
Assembly Test Results: 9PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
12203
Water District/Authority:f-4 Account:
Contact Person:
Facility Name: l "#P hk�(-S
Contact Phone:
Service Address: ,9)5 fit,,n�P ir-ci'/ DI 1F4 r'olljt .S t1O
a Mailing Address:
V! ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
2 Company Name/Title:
Contact Phone:
0I
Mailing Address:
Make: F�Fy
Model: 7C�, Size: 314
Type: ❑ RPZ ❑ DC ,] PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
a` Date Installed: Location on Property: i
'57cir o� he,..) -se
❑ Replacement Device
Orientation
Service
Protection
tp previous device serial #
Inlet: Outlet:
❑ Domestic
❑ Containment
Q
Vertical Up ❑
❑ Fire Isolation
New Installation
❑ Vertical Down ❑
`� Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal?
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
.
Tightness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Ti htness Differential
Check Valve #1
❑ Leak
/ nn
Ck#1
❑ Leak
iRPZ, DC; FVB,-SVB
0 Tight
/ O
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
c Relief Valve
RV
W RV, RPZ
ElDiaphragm ❑ seat
❑ other
Repaired:
Cleaned:
c Buffer
0 RPZ
❑ Air Inlet
ElAir Inlet
et{ Air Inlet
Air Inlet
iT Air inlet, PVB, SVB
'6
❑ poppet ❑ bonnet
❑ other
C
Shutoff Valve #1 ❑Leak Ticlht
SOV #1 ❑ Open Upon Arrival Open At De arture Backpressure exists? ❑YES ❑ NO
Shutoff Valve #2 ❑Leak V3 Ti ht
SOV #2 ❑ O en U on Arrival ❑ O en At Departure Cause
Assembly Concerns: est Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation ❑ ABPA It ASSE
❑ Incorrect Use
Turn off date: Turn on date:
Turn off time: Turn on time:
0 Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # aB995
o Person Notified: A 1k Contacted by:
Z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: G az)12
1 hereby certify that the isolatiorVShutoff Valves (SOP # 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 District/Authority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backf/ow (please print)
y
Testing Company: Testln_q LLC Phone: 970-352-3090 Customer Name: Phone:
F'
(please print))
Tester Name: AJ Simonson Tester Signature: it ll A- Customer Signature:
Backflow testers who test or repair assemblies on/a fire line must be registered with the Colorado Division of Fire Safety.