HomeMy WebLinkAbout2301 Ballard Ln - Special Inspections/Backflow - 11/01/2012CONSULTING - TESTING -SALES- REPAIRS
INSTALLATION -EMERGENCY SERVICES Assembly Serial #: #"-709.9 -
4 A 's Bach ' ?� T sti LLC Test Date/Time: 11- 1-►7_ ;t!ano
.� Gauge Serial #: n5p45 nee
"YourCros5-Connection Connection" District Required Info: Gp
154027th street, Greeley, CO 80631 Tester Certification #: 775r7
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794 Date Certification. Expires: 3n-/�
Website: ajsbackflowtesting.com E-mail: ajsbft@"nhlink.net p ��
Assembly Test Results: X PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report 12546
Water District/Authority: ZLcAccount: Contact Person:
o. Facility Name: T e Contact Phone:
Service Address: ..230 1 ,�J L�><_///,mot /o f3osz4
a� Mailing Address: :522,0 ,>
UI ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
0,
Mailing Address:
Make: rPhca Model: -766 Size: 314
Type: ❑ RPZ ❑ DC /V PVB ❑ SVB ❑ Air Gap . ❑ AVB ❑ Other Device
Z. Date Installed: Location on Property: Ali Side D-Fhox-e
E ❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q Vertical Up ❑ ❑ Fire ti' Isolation
New Installation ❑ Vertical Down ❑ Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Og
Tightness Differential
❑ C1<#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
'Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
�1
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ, DC
❑Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
N RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
ail Air Inlet.
Air Inlet
IX Air inlet, PVB, SVB
C
I
/ 16
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak JH Tight
SOV #1 ❑ Open Upon Arrival V Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause .
Shutoff Valve #2
❑Leak Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture
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 #( Z B995
c Person Notified: AAA- Contacted by:
Z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: _s- _-20-tz
I hereby certify that the isolation/Shutoff Vatves (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 District/Authority shown above) and the test readings are true and accurate to the best or my ability.
(please print) A✓S BackNow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies a fire line must be registered with the Colorado Division of Fire Safety.