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HomeMy WebLinkAbout2507 Bar Harbor Dr - Special Inspections/Backflow - 04/17/20134, CONSULnW •TESTING • S4LES • REPAIRS r a j INSTAL(ATION•EMERGENC tYSERVICES T AJ'S Back Tow Testing LLC ` "Your Cross-ConructionConnection" 1540 27th Street, Greeley, CO 80631 Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794 Website: ajsbackfiowtesting.com E-mail: ajsbftCsearthlink.net Assembly Serial #: Test Date/Time: Gauge Serial #: District Required Info: r t •' W#JP i_�_' Tester Certification #: �f5© Date Certification Expires: Backflow Prevention Device Test & Maintenance Report 13053 Water District/Authority: !�'LGy Account: Contact Person: �. Facility Name: �f�GLr ne X • - Contact Phone: Service Address: 25p7 L'n s lQ 9oS;;-,4 _�" Q Mailing Address: < m09 (❑ Owner ❑ Manager ❑ Contractor C�. ❑ Other Contact Person: 2 Company Name/Title: Contact Phone: a) Mailing Address: Make: -r %CO Model: %S Size: 414' Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device /Q Date Installed: Location on Property: '5-,C,4L,_xk_ ��cP is ❑ Replacement Device Orientation Service Protection previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment Q iS Vertical Up ❑ ❑ Fire `O'lsolation New Installation ❑ Vertical Down ❑ AD Irrigation ❑ Containment by Isolation ❑ Stolen ❑ Horizontal ,YC7 ❑ Other: Line PSI: Initial Test Results: Repaired: Cleaned: Re -test Results: Ti htness Differential Ti htness Differential ❑ ck#1 ❑ ck#2 El RV ❑ ck#t ❑ ck#z ❑ RV Check Valve #1 ❑ Leak Ck#1 ❑ Leak RPZ, DC, PVB, SVB )J Tight ❑ disc ❑ spring ❑ seat ❑ other ❑ Tight Check Valve #2 ❑ Leak Ck#2 ❑ Leak V RPZ, DC ❑ Tight ❑ disc ❑ spring ❑ seat ❑ other ❑ Tight Relief Valve RV RV, RPZ ❑ Diaphragm ❑ seat Repaired: ❑ other Cleaned: c Buffer RPZ ` ❑ Air Inlet Air Inlet ❑ Air Inlet of, Air Inlet Of Air inlet, PVB, SVB ❑ poppet ❑ bonnet ❑ other C Shutoff Valve #1 ❑ Leak In Ti ht SOV #1 ❑ Open Upon Arrival ❑ Open At Departure Backpressure exists? ❑ YES ❑ NO SOV #2 ❑ Open Upon Arrival ❑ Open At Departure Cause F' Shutoff Valve #2 ❑ Leak Pr Tight 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 #13 B995 o Person Notified: Contacted by: 2r Turn off date/time: Turn on date/time: Y Test Kit Make: Mid -West Model: 845 Last Calibration Date: I hereby certify that the isolatiorushutoff Valves (SOV # I 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 DistricVAuthodty shown above) and the test readings are true and accurate to the best of my ability. (please print) AJs BecM/ow (please print) m Testing Company: Testing LLC Phone:- 970-352-3090 Customer Name: Phone: F- (please print)) Tester Name: AJ Simonson Tester Signature: Customer Signature: Backflow testers who test or repair assemblies,6n a fire line must be registered with the Colorado Division of Fire Safety.