HomeMy WebLinkAbout2226 Maple Hill Dr - Special Inspections/Backflow - 04/20/2013CONSULTING -TESTING -SALES -REPAIRS
INSTALLATION - EMERGENCY SERVICES
9gjts Bac Tow Tie'sring 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: ajsbft0eanhlink.net
Assembly Serial #:
N 7/So30
Test Date/Time:
42t>`13 576A01
Gauge Serial #:
o5oa gc5A-q
District Required Info:
Tester Certification #:
7950
Date Certification Expires:
11-30-/5
Assembly Test Results: Y PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
13075
Water DistricVAuthority: ECZCv Account: Contact Person:
Facility Name:--L-LrAey Contact Phone:
- Service Address: o? & /Yi4Pr'P Wt't J Or .F 4 <GN A- 5 e0 8�5.74
Mailing Address: 5-alne
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name[Title: Contact Phone:
Mailing Address:
Make: Feb eo Model: 76,T Size: 3�4
�m Type: ❑ RPZ ❑ DC )C PVB ❑ SVB .-_ 0 Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: (C% r SdP O4r'ioL "Se
❑ Replacement Device Orientation Service Protection
previous device serial At Inlet: Outlet: ❑ Domestic ❑ Containment
*' Vertical Up ❑ ❑ Fire Isolation
] New Installation ❑ Vertical Down El Irrigation El Containment by Isolation
❑ Stolen 3. ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
°
E�D
Ti htness Differential
Ti htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
1- D
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV. RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
p
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
❑ poppet et ❑ bonnet ❑ other
Shutoff Valve #1
1 ❑ Leak Tight
SOV #1 Open Upon Arrival ❑ Open At Departure Backpressure exists? ❑ YES ❑ NO
SOV #2, 9 Open Upon Arrival ❑ Open At De arture Cause
Shutoff Valve #2
1 ❑Leak Tight
Assembly Concerns:
Test Procedure:
Comments:
(only it applicable)
❑ Incorrect Installation
❑ ABPA 0 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 8995
Person Notified:' ..' ' ' Contacted by:
Turn off date/time: Turn on date/time:
x�- Test Kit Make: Mid -West Model: 845 Last Calibration Date:
_- I hereby certify that the isolatior✓ShutoH 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.
(please print) AJs Backfidw (please print)
,41- Testing Company: Testing LLC Phone: 970-352-3090 Custo er Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies- n a fire line must be registered with the Colorado Division of Fire Safety.