HomeMy WebLinkAbout2542 Lynnhaven Ln - Special Inspections/Backflow - 07/22/2013CONSULTING •TESTING • SALES -REPAIRS
INSTALLA1ION -EMERGENCYSERVICES
?{J's Bac Tow 9esting 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: ajsbft@earthlink.net
Assembly Serial #: IC-2,0,2 yn/ 8
Test Date/Time:
Gauge Serial #: _ O sc)Socy r'�9
District Required Info:
Tester Certification #: 7g/sv
Date Certification Expires: /I-3v is
Assembly Test Results: ❑ PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
14262
Water District/Authority: E-1 e-o Account: Contact Person:
Facility Name: v�x-nm„ /�i P4 Contact Phone:
Service Address: a s4c;2 12 ,,, An,--Pn /r, l�_11tb sin fir)s-2n
MailingiAddress: �nn7P
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
'a Company Name/Title: r Contact Phone:
Mailing Address:
Make: I, ) � �2 t In Model: 7o20 11 Size: —314
N Type: ❑RPZ ❑ DC PVB ❑SVB ❑Air Gap ❑ AVB ❑Other Device
Date Installed: Location on Property: S lol-ilPr— A&-Ke
i? ❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire Olsolation
New Installation ❑ Vertical Down ❑Irrigation ❑Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results,.
Repaired: Cleaned:
Re -test Results:
❑ Ck#1 ❑ Ck#2 ❑ RV ❑ Ck#1 ❑ Ck#2 ❑ RV
Ti htness Differential
Tightness Differential
Check,Valve #1
❑ Leak
Ck#1
❑ Leak
tr RPz, DC; PVB, SVB
Tight t� ZS
❑ disc ❑ s rin ❑ 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
Repaired: Cleaned:
Buffer
?g RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
1 .-❑ Leak V Ti ht
SOV #1 ❑ Open Upon Arrival ET Open At De arture Backpressure exists? ❑ YES ❑ NO
Shutoff V81V@ #2
❑Leak Tic
re Cauuse
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
(: ❑ Incorrect Installation
❑ ABPA® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turnoff time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 13 B995
I Person Notified: AA Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Lasf Calibration Date:
1 I hereby certify that the isolatiorvshutoff Valves (SOV # 1 and SOV #2) have been returned to the position in which they were round 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 or 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: // Customer Signature:
Backflow, testers who test or repair assemblies on dArdrline must be registered with the Colorado Division of Fire Safety.