HomeMy WebLinkAbout414 Bow Creek Ln - Special Inspections/Backflow - 11/14/2012CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
i{g's BacG TOW Testinq LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsback0owtesting.com E-mail: ajsbft@earthlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #:
District Required Info:
C�
I1-14-1z 11,15A
o�jcysaoBrr
Tester Certification #: ";9-50
Date Certification Expires: // 3o'r Z
Backflow Prevention Device Test & Maintenance Report
PASS ❑
Ri ,P r, ,S
Water District/Authority: *-f <dll u—> /lci e+/ Account: Contact Person:
�. Facility Name: ��cXx^PV Contact Phone:
Service Address:
Q Mailing Address:i �A7P
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
CAI
Company Name/Title: Contact Phone:
0,
Mailing Address:
Make: F-><'bro Model: 7Z' Size: 3%4
Type: ❑ RPZ ❑ DC PVB O SVB ❑ Air Gap ❑ AVB ❑ Other Device
a Date Installed: Location on Property: W, S;�lPoG rsnyse
d❑ Replacement Device Orientation Service Protection
rp previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q ,Q Vertical Up ❑ ❑ Fire JB Isolation
❑ Vertical Down ❑ >2 Irrigation ❑ Containment by Isolation
New Installation
❑ Stolen ❑ Horizontal `!<] ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Con
Ti htness Differential
Ti htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight"?
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
a Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned:
Buffer
gRpz
❑ Air Inlet
❑ Air Inlet
4 Air Inlet
Jr
/
Air Inlet
C Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak �4D Tight
SOV #1 ❑ Open Upon Arrival >171 Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
�. Shutoff Valve #2
❑ Leak Ti ht
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA M ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification 47, B995
Person Notified: Contacted by:
.A
z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certily that the isolatior✓ShutoBValves (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 Bacid/ow (please print)
d Testing Company: Testing LLC Phone: 970-352-3090 stomer Name: Phone:
E (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.