HomeMy WebLinkAbout2601 Bar Harbor Dr - Special Inspections/Backflow - 04/19/2013CONSULTING • TESTING • S4LES • REPAIRS
INSTALLATION • EMfRGENCYSERVICES
4#
AJ's Bac Tow Testing LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbfirgearthlink.net
Assembly Serial #:
:714g4 jz�
Test Date/Time:
if--r 3 q 14-4Afn
Gauge Serial #:
eoS StxaF� r
District Required Info:
Tester Certification #:
/ ;50
Date Certification Expires:
/! ?d)t�-
Assembly Test Results:,] PASS []FAIL
Backflow Prevention Device Test & Maintenance
RL - ITT
cWater District/Authority:
Account: Contact Person:
Facility Name: /60nws
Contact Phone:
Service Address: a2 (Po I i sk r fir fir— i 4 ,,-o lz ks to SSA
Mailing Address: Sct1771-1
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
10,
Company Name/Title:
Contact Phone:
0,
Mailing Address:
Make: bra
Model: Size: 3/4
Type: ❑ RPZ ❑ DC] PVB
❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: Sr 5t de G"?"3F XWSr
E ❑ Replacement Device
Orientation Service Protection
previous device serial #
P
Inlet: Outlet: El Domestic ❑Containment
X Vertical Up ❑ ❑ Fire >E7 Isolation
New Installation
❑ Vertical Down ❑ >91 Irrigation ❑ Containment by Isolation
4 N Stolen
I
❑ Horizontal ` J ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
26
Tightness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ElRV
Tightness Differential
Check Valve #1
❑ Leak
r
Ck#1
❑ Leak
RPZ, DC, I?VE SVB
] Tight
r
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
cc Relief Valve
RV
'.. RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
O
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
I Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak Ti ht
SOV #1 ❑ Open Upon Arrival ❑ Open At Departure Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
❑ Leak )8 Tight
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:
a
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification #t 3 B995
.40
Person Notified: 4A Contacted by:
Z)
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolationlShutoff 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 DistdcUAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJS Backflow (please print)
d Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: G 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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