HomeMy WebLinkAbout511 Coyote Trail Dr - Special Inspections/Backflow - 09/15/201222
CONSULTING - TESTING -SALES -REPAIRS
INSTALLATION -EMERGENCY SERVICES
16 Ag's Back�ow Tjestillg LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbft@s rthlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #:
District Required Info:
Tester Certification #:
Date Certification
q-1S-/z ld,37API,
oSd Sao A 9
Assembly Test Results:
Backflow Prevention Device Test & Maintenance
Wccy
'r 0—/2
PASS ❑ FAIL
12256
Water District/Authority: f4 loll. t, -5IZ4 .,c) Account: Contact Person:
3 Facility Name:--i�r%r-necl Contact Phone:
Service Address: _g"i I e, 04 e 'TM : ( Dl- r4- ro/%1, _s
a Mailing Address: 57Z,'Aff'ro
(❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
C).
g. Company Name/Title: Contact Phone:
01 Mailing Address:
Make: Model: 76S Size: -7/d
Type: ❑ RPZ ❑ DC /8 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: S d��oL7Se
E ❑ Replacement Device Orientation Service Protection
0 previous device serial # Inlet: Outlet. ❑ Domestic ❑ Containment
4 jL] Vertical Up ❑ ❑ Fire /Cl Isolation
New Installation ❑ Vertical Down ❑ J8 Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal l` ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
coo
Ti htness Differential
Ti htness Differential
❑ Ck#t ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
)ED Tight
cr7
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
W Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
el{ Air Inlet
It (o
Air Inlet
pJ Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1
1 [OIL ak Tight
SOV #1 0 Open Upon Arrival SQ Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
�- Shutoff Valve #2
1 ❑ Leak Tight
SOV #2iEl Open Upon Arrival `❑ Open At Departure
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
°
Turn off time:
Turn on time:
uAlarm Company/Fire Department Notified: ❑ Fire suppression contractor certification #72 B995
c Person Notified: Contacted by:
z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:
1 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 DistrictlAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
f- (please print)) l /J
Tester Name: AJ Simonson Tester Signature: if%1/ Customer Signature:
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety.
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