HomeMy WebLinkAbout2612 Forecastle Dr - Special Inspections/Backflow - 02/07/2013CONSUL77NG -TESTING -SALES -REPAIRS
INSTALLATION . BtfERGENCYSERWCES
%Ts Bac �ow ?_esting LLC
"Your Cross -Connection Connecrimt"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Websiwapbeckeowtesting.com E-mail: ajsbft4eanhlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #:
District Required Info:
Tester Certification #:
Date Certification Expires:
Backf low Prevention Device Test & Maintenance Report
.J-7-/Z $'i22fjM
bSt/ 5�., GZry
_21". 12
12815
Water District/Authority: C/ rd Account: Contact Person:
Facility Name: __—J—A.'Y-AeJ 6vs1P5 Contact Phone:
8 Service Address: .2Cal? e-e i,ks <wPet5aA
a Mailing Address: sc MP
V❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Name/Title: Contact Phone:
C Mailing Address:
Make: f PGCa Model: 76 S Size: 3/4
Type: ❑ RPZ ❑ DC J PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: _ nl 5' jezxC kWS, �P
'E ❑ Replacement Device Orientation Service Protection
tI previous device serial At Inlet: Outlet. ❑ Domestic ❑ Containment
Q I �0 Vertical Up ❑ ❑ Fire >2 Isolation
New Installation ❑ Vertical Down ❑ I)E( Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal U' ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck41 ❑ ck#2 ❑ RV
Re -test Results:
_�5
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
�l
d, V
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
Ei RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seal ❑ other
❑ Tight
e Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
c Buffer
Repaired: Cleaned:
RPz
❑ Air Inlet ❑ Air Inlet
qj Air Inlet
0
Air Inlet
IM Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
t
Shutoff Valve #1 El Leak 10 Tight SOV #1 ❑ Open Upon Arrival Open At Departure Backpressure exists? ❑YES ❑ NO
F; Shutoff Valve #2 1 ❑ Leak 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 # ,� B995
°❑
Person Notified: !� Contacted by:
Z Turn off date/time: Turn on date/time: '
r� Test Kit Make: Mid -West Model: 845 Last Calibration Date: z)a6a
I hereby certify that the isolationIShutoN 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 DistricVAuthodly shown above) and the test readings are true and accurate to the best of my ability.
m (please print) AJs Back low (please print)
y Testing Company: Testing LLC Phone: 970 352-3090 Cu toner Name: Phone:
F" (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies on'a fire line must be registered with the Colorado Division of Fire Safety.