HomeMy WebLinkAbout2613 Bar Harbor Dr - Special Inspections/Backflow - 04/17/2013CONSULTING -TESTING - SALES - REPAIRS
INSTALLATION- EMERGENCY SERVICES
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Assembly Serial #: 7/ ,513 -.
A 's Bac(Tow?ewstng LLC
Testgate :
Gauge Serial #:
4 / 7-iZ 23S
D.S�xS"ao89
'Tour Cross-ConnecnonConnecnmt"
District Required Info:
1540 27th Street, Greeley, CO 80631
Tester Certification #:
7450
Office 970-352-3090 Call 303-981-7032 Fax 970-356-5794
Date Certification Expires:
//-39^f5
Website: ajsbackflowtesting.com E-mail: ajsbft9eanhlink.net
Assembly Test Results:
[PASS El FAIL
/
Backflow Prevention Device Test & Maintenance Report
I Water District/Authority: £LGO Account: Contact Person:
3 Facility Name: 5 Contact Phone:
Service Addres F-4-
a Mailing Address: S4^ e
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
UI
2 Company Name/Title: Contact Phone:
0 Mailing Address:
Make: 4ebcO Model: ?&S Size: 3 4
Type: ❑ RPZ ❑ DC 7 PVB ❑ SVB ❑ Air Gap ❑/ AVB ❑ Other Device
S SL+Q /�XSP
2'
Date Installed: Location on Property:
A
E
❑ Replacement Device Orientation Service Protection
Nprevious
device serial If Inlet: Outlet. ❑ Domestic ❑ Containment
4.1
?1j Vertical Up ❑ ❑ Fire Isolation
❑ Vertical Down ❑llrrigation ❑ Containment by Isolation
0 New Installation
I
Stolen ❑ Horizontal )F! ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned: 1
Re -test Results:
5
Ti htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2;i.6 RV
Ti htness Differential
Check Valve #1
❑ Leak
/ Q
Ck#1 r (
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v. RPZ, DC
❑Tight
❑disc ❑ spring ❑ seat ❑ other
❑ Tight
c Relief Valve
RV
CRV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned:
Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
etf Air Inlet
Air Inlet
I Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1 1 ❑ Leak Tight I SOV #1 ❑ Open Upon Arrival ❑ Open At Departure Backpressure exists? ❑ YES ❑ NO
�. Shutoff Valve #2 ❑ Leak Ti ht SOV #2 ❑ Open Upon Arrival ❑ Open At De arture 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: 4 Fire suppression contractor certification # 13 B995
c Person Notified: /iM 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 isolatiorVShuto#Valves (SOV #1 and SOV #2) have been returned tothe position in which they were found and that the last test was done according to
the procedure shown above required by the Water DistdcUAuthonty shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backf/ow (phase print) Zy4
d Testing Company: Testin-g LLC Phone: 970-352-3090 _Customer Name:% Phone:
(please print))'
`.
I( Tester Name: AJ Simonson Tester Signature: �jt.. ` Customer Signature:
Backflow testers who test or repair assemblies onAa fire line must be registered with the Colorado Division of Fire Safety.