HomeMy WebLinkAbout508 San Juan Dr - Special Inspections/Backflow - 03/12/2013CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
,qys Bac �ow Te'st1Yg LLC
"Your Cross -Connection Connection"
1540 27th street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft9eanhlink.net
Assembly Serial #: A 6 7
TestDatelTime: -/Z-/3 tl xUAm
Gauge Serial #: e7!5_-.3 :zr� A-9
District Required Info:
Tester Certification #: 795n
Date Certification Expires: lk3trI5,
Assembly Test Results:70 PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
12951
Water District/Authority: _C4 6ollrl,5 Account: Contact Person:
3 Facility Name: o, Contact Phone:
Service Address: Sr7 „ T,r ,. r d �.�1/,� t -�o s
Q Mailing Address: So m
V� ❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
0 Company Name/Title: Contact Phone:
Mailing Address:
Make: .� �P !vim Model: %/A s Size: 31d
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap1 ❑ AVB ❑ Other Device
/0
2 Date Installed: Location on Property: CN ` ' �P d.( houSP
d❑ Replacement Device Orientation Service Protection
v� previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Q ® Vertical Up ❑ ❑ Fire 9 Isolation
IyLI New Installation ❑ Vertical Down ❑ Irrigation ❑ Containment by Isolation
❑Stolen ❑ Horizontal d ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re test Results:
S
Ti htness Differential
Tightness Differential
❑ C1#1 ❑ C1#2 ❑ RV
❑ ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
P Tight
'2
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
V RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
m RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
�,6
Air Inlet
IM Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1
❑Leak Tight
1SOV#1 ❑ open Upon Arrival Open At De arture
Backpressure exists? El YES ❑ NO
Cause
rA.
Shutoff Valve #2
❑ Leak Tight
SOV #2 ElOpen Upon Arrival ❑ Open At Departure
Assembly Concerns:
T st 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 # 1 f B995
-❑
c Person Notified: /�' Contacted by:
Z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: S-. v 1_2
1 hereby certify that the isolation/Shutolf 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 District/Authority shown above) and the test readings are true and accurate to the best of my ability.
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r!
(please print) AJs BackNow (please print)
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Testing Company: Test/n_q 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,on a fire line must be registered with the Colorado Division of Fire Safety.
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