HomeMy WebLinkAbout529 Coyote Trail Dr - Special Inspections/Backflow - 09/17/2012CONSUL77NG • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
Ag's Bac Tow fisting LLC
"Your Cross -Connection Connection"
IMO 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbftgearthlink.net
Assembly Serial #: N :7ooS3P-
TestDate/Time: er-1 iZ 1A&Aw
Gauge Serial #: hSnSe0eb`t
District Required Info:
Tester Certification #: -74 S�
Date Certification Expires: It-3 0-I Z.
Assembly Test Results: ;E PASS ❑
Backflow Prevention Device Test & Maintenance Report
F. -
Water District/Authority: r� cc) Yo, sl' / oue (A, ci Account: Contact Person:
�. Facility Name: a,r ' P r W Contact Phone:
Service Address: ,cP T r 4.1
Q� Mailing Address: Sct �e
t�I ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Name)Title: Contact Phone:
�)
Mailing Address:
Make: bcd Model: Size: J14
Type: ❑ RPZ ❑ DC �L7 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
a Date Installed: Location on Property: Cr Sd P 0.� koase
a
d El Replacement Device Orientation Service Protection
m previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
< �111 Vertical Up ❑ �l Fire Isolation
/❑
❑ New Installation Vertical Down ❑ jc Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal `❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
5r
Tightness Differential
Tightness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
A Tight
�'
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
S Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
otf Air Inlet
Air Inlet
Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1
❑ Leak XTiqht
SOV #1 ❑ Open Upon Arrival A Open At De arture
Backpressure exists? ❑ YES ❑ NO
F Shutoff Valve #2
❑ Leak? Ti ht
SOV #2 Elopen upon Arrival ❑ Open At Departure
Cause
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:
�+ Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification #12- B995
AJA
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: Via°"
I hereby certify that the isolatior✓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 i o
the procedure shown above required by the Water DistricUAuthonty shown above) and the test readings are true and accurate to the best of my ability.
r (please print) AJs Backfiow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t ' (please print)) 44
-
Tester Name: AJ Simonson Tester Signature: N`�" Customer Signature:
Backflow testers who test or repair assemblies Offal fire line must be registered with the Colorado Division of Fire Safety.