HomeMy WebLinkAbout408 Bow Creek Ln - Special Inspections/Backflow - 11/14/2012CONSULTING • TESTING • S4LES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
_%g's Back Tow '1 e'sting LLC
"Your Cross-Connechi m Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft@earthlink:net
Assembly Serial #: H 70"7 IrS I
TestDate/Time: it d1Ah
Gauge Serial #: -)5je;, senosc,
District Required Info:
Tester Certification #: 2<j; o
Date Certification Expires: 1130-17
Assemblv Test Results/] PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
12600
c Water DistricVAuthority:4;; t Account: Contact Person:
Facility Name: r s Contact Phone:
Service Address: 408 RotLa l'r-e-P k Ln ,F4- GAksro S05.7s--
Mailing Address: 5r. pytea
a ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company NamelTitle: Contact Phone:
Mailing Address:
l�j Make: b co Model: Size: No
k L Type: ❑ RPZ ❑ DC E PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: S coed-j7AovSP
v
E ❑ Replacement Device Orientation Service Protection
previous device serial If Inlet: Outlet: ❑ Domestic ❑ Containment
Q` `E] Vertical Up ❑ ❑ Fire 1�? Isolation
07,1
New Installation ❑ Vertical Down ❑ girrigation ElContainment by Isolation
Stolen ❑ Horizontal ❑ Other:
Vo
` Line PSI:
Initial Test Results:
Repaired: Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
-,;,_ RPZ, DC, PVB, SVB
�ryJ
Tight tY` °2
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
--❑ Leak
Ck#2
❑ Leak
RPZ, DC
d Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
c Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
od Air Inlet
Air Inlet
Air inlet, PVB, SVB
'
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1 1 ❑ Leak AD Ti ht ISOV#1 ❑ Open Upon Arrival Open At Departure Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2 1 ❑ Leak �O Tight I SOV #2 ❑ Open 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 # (2p B995
Person Notified: AAN Contacted by:
12 Turn off date/time: Turn on date/time:
F
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
.i 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 DistricUAuthonty shown above) and the test readings are true and accurate to the best of my ability.
ar (please print) AJs Backfiow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
fi (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblie on a fire line must be registered with the Colorado Division of Fire Safety.