HomeMy WebLinkAbout2501 Bar Harbor Dr - Special Inspections/Backflow - 04/17/2013CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
%3's Bac Tow T stting L EC
"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: ajsbft@earthlink.net
Assembly Serial #:
P -715
Test Date/Time:
Gauge Serial #:
OD8
District Required Info:
Tester Certification #:
50
Date Certification Expires:
5
PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
13052
Water District/Authority: f=2CO Account: Contact Person:
Facility Name: p Contact Phone:
Service Address: r r6or ,47 P:7 �) >7 < la 9aSa24
Mailing Address: 56^ me
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Narr itle: Contact Phone:
Mailing Address:
Make: -,Phva Model: 7dS Size:Z4
Type: ❑ RPZ ❑ DC PVB O SVB O Air Gap O AVB ❑ Other Device
Date Installed: Location on Property: 4S.-)7 O�r- "5i0
❑replacement Device Orientation Service Protection
previous device serial At Inlet: Outlet. ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire Isolation
New Installation ❑ Vertical Down ❑ Irrigation ❑ Containment by Isolation
O Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
FCleaned:
k#1 ❑ Ck#2 ❑ RV
Re -test Results:
Ti htness Differential
Ti htness Differential
Check Valve #1
O Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
/
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
IS.
RV
RV, RPZ
❑ Dla hra m ❑ seat ❑ other
Repaired: Cleaned:
Buffer
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlett
Air Inlet
j Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
. Shutoff Valve #1 1 ❑ Leak Tight SOV #1 O Open upon Arrival ❑ Open At Departure Backpressure exists? O YES O NO
Shutoff Valve #2 1 ❑ Leak Tight SOV #2 ❑ Open Upon Arrival ❑ Open At Departure Cause
Assembly Concerns:` 4est 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
Person Notified: IC Contacted by:
J.O
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby ner that the isolation/Shutoff VaNes (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/Authonty shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Baekflow (please print)
Testing Company: Testirya LLC Phone: 970-352-3090 Cust er Name: Phone:
(please print))
Tester Name: AJ SimOnsOn Tester-' Signature: / Customer Signature:
Backflow testers who test or ;re air assemblies on a fire line must -be registered with the Colorado Division of Fire Safety.