HomeMy WebLinkAbout2207 Ballard Ln - Special Inspections/Backflow - 11/01/2012CONSULTING • TESTiNG • SALES • REPAIRS
INSTALLAT70N•EMERGE�N,C-Y�SERVICES
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Assembly Serial #: (o J6.97
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S BCiGi� 1 �St1C
Test Date/Time: i/-J-�7 ron
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Gauge Serial #: czs�
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District Required Info:
154027th Street, Greeley, CO 80631
Tester Certification#: -7esn
Office970-352-3090 Cell303-981-7032 Fax970-356-5794
Date Certification Expires: �-
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Website: ajsbackttowtesting.com E-mail: ajsbft(h'earthlink.net
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Assembly Test Results: PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report 12539
Water District/Authority: </-r
Account:
Contact Person:
Facility Name: r
Contact Phone:
Service Address: e,7e2 n 1 ..//,r4.J
Z n r 4 e-0AL-
in
Qi Mailing Address: 54 Avo
CtI ❑ Owner ❑ Manager ❑ Contractor . ❑ Other
Contact Person:
2 Company NamelTitle:
Contact Phone:
c1
Mailing Address:
Make: Feb c-a
Model: 7g
Size:
Type: ❑ RPZ ❑ DC] PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: le,
5 "ek' c �o
d ❑ Replacement Device
Orientation
Service
Protection
ep previous device serial #
Inlet. Outlet.
❑ Domestic ❑
Containment
a'
Vertical Up ❑
O
❑ Fire Isolation
Iy��7New Installation
Vertical Down ❑
irrigation ❑
Containment by Isolation
YU Stolen
❑ Horizontal
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Ti htness Differential
❑ Ck#t ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Ti htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
D
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
w Relief Valve
RV
d RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
Air Inlet
01 Air inlet, PVB, SVB
C
Irrb
❑ poppet ❑bonnet
❑other
Shutoff Valve #1
❑Leak Ti ht
SOV #1 ❑ Open Upon Arrival ROpen At Departure,
Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak Ti ht
SOV #2 ❑ Open Upon Arriva ❑ 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 # M B995
c Person Notified: AAA Contacted by:
z Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: 5--;;�o-q --7-
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 DistricUAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backfiow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t ' (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies o /a ire line must be registered with the Colorado Division of Fire Safety.
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