HomeMy WebLinkAbout2536 Lynnhaven Ln - Special Inspections/Backflow - 07/22/2013CONSULTING • TESTING -SALES -REPAIRS
INSTALLATION - EMERGENCY SERVICES
�[ J's Back�ow fisting LLC
"YourCross-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: ajsbft9earthlink.net
Assembly Serial #:
Test Date/Time:
Gauge Serial #: 0-1 n;
District Required Info:
Tester Certification #: 7g-sn
Date Certification Expires: //-.3�)-/5-
Assembly Test Results: JJ PASS ❑ FAIL
Backtlow Prevention Device Test & Maintenance Report
1.4266
Water District/Authority: I�Z e-o Account: Contact Person:
Facility Name: At-me-s Contact Phone:
Service Address: ' hn.oA Lh r-j Koll,k
Mailing Address: rnP
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
®
Mailing Address:
Make: Model: 7,704 Size: 314
Type: ❑ RPZ ❑ DC XPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: S,,J e 0-C %JS-P
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
fl" Vertical Up ❑ ❑ Fire 'Isolation
New Installation ❑ Vertical Down ❑ )R Irrigation ❑ Containment by Isolation
L
Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
io5"
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, Sve
'Tight
°2
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
1 RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
y RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired:
Cleaned:
Buffer
RPZ
❑ Air I let
❑ Air Inlet
Air Inlet
Ae nlet
Air inlet, PVB, SVB
G
t❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak Tight
SOV #1 ❑ Open Upon Arrival Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
1 ❑ Leak Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
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: ❑ Fire suppression contractor certification # 17, B995
Person Notified: AAA Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
e `,) I hereby certify that the isolatiorvshutoff 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 dry ability. .
(please print) AJs Backtiow (please print),
Testing Company: Testing LLC Phone: 970-352-3090 Custo er Name: Phone J
(please print))
Tester Name: AJ Simonson Tester Signature: - 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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