HomeMy WebLinkAbout427 Bow Creek Ln - Special Inspections/Backflow - 03/22/2013CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
ATs Back Tow fisting LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfioatesting.com .E-mail: ajsbft@earthlink.net
Assembly Serial #: 479: AZ!;
Test Date/Time: 3 2z-{ 3 f 1/7/W
Gauge Serial #: oSeSoo_
District Required Info:
Tester Certification #: 94S'o
Date Certification Expires:
Assembly Test Results:W PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
Water District/Authority: 4::f- <oI/kS/Zc, i.t d Account:
Contact Person:
3 Facility Name: ;;,0VrrlT lIhA1eS
Contact Phone:
$ Service Address: 4�7 /3osv•rr-Pek
Lm ;74 6;/1lari e-^ 005.2S
a Mailing Address: !�G Ine
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
V:
2 Company Name/Title:
Contact Phone:
01
Mailing Address:
-
Make: (-eb,D
Model: .7is-
Size:
Type: ❑ RPZ ❑ DC )i PVB
❑ SVB ❑ Air Gap,.
❑ AVB . ❑ Other Device
Date Installed: -: Location on Property: 'A% =<%
W a-:(
E ❑ Replacement Device,
Orientation
Service = Pfdtectlon
rA previous device sera{ #`
Inlet. Outlet;. '
❑ Domestic ❑ Containment
Q
A Vertical Up
❑ Fire Isolation
New Installation.y
❑ Vertical Down
eE Irrigation ❑ Containment by Isolation
❑ Stolen
❑ Horizontal
❑ Other:
Line PSI:
Initial Test Results:
Repaired: '..
Cleaned:
Re -test Result's:•
❑ Ck#1 ❑ Ck#2 ❑ Rv":
❑ Ck#1 ❑ Ck#2 ❑ RV
$ :
Ti htness Differential
Ti htness Differential -
Check Valve #1
❑ Leak
'>U
b
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat
' ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v. RPZ, DC
El Tight
disc ❑ spring El seat
❑:other:..
❑Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑other
• _:.••
Buffer
Repaired:
=:=
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
oti Air Inlet,
b
Air Inlet
IM Air inlet, PVB, SVB
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1 ❑ Leak �aTiaht
SOV#i open upon Arrival 'Oen At Departure Backpressure;ezists4 " ❑ YES- ❑ NO
�• Shutoff Valve #2 ❑ Leak Tight .
., :.
SOV #2 El. Open, U on,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:
wIAlarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 13 B995
o Person Notified: �� 'Contacted by:
z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:
l hereby certify that the isolatior✓Shuto# 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 DistricUAuthonly shown above) and the test readings are true and accurate to the best or my ability.
m (please print) Ads Backflow (please print)
Testing Company;• Testing LLC Phone: 970-352-3090 Cust mer 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.