HomeMy WebLinkAbout2549 Lynnhaven Ln - Special Inspections/Backflow - 08/08/2013CONSULTING •TESTING •S4LES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
A,7's Bac6f&wTesting LLC
"Your Cross -Connection Connection„
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Websim ajsbackilowtesting.com . E-mail: ajsbft@ewhlink.net
Assembly Serial #: r 30a5/J/
Test Datelfime: 43-t3)3 9i7G0*'
Gauge Serial #: �n :jL):M. 0 P 4
District Required Info:
Tester Certification #: 79So
Date Certification Expires: it-3o-i5
Backflow Prevention Device Test & Maintenance Report
14535
Water District/Authority: re- co Account: Contact Person:
Facility Name: 2—rnu,rr e* z4me3 Contact Phone:
Service Address: -2 <,d y /!5,A
Mailing Address: -1.14 the—/
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: bj" k'V S Model: 25:,Y2 Size:
Type: ❑ RPZ ❑ DC RPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
' Date Installed: Location on Property: 5; Sr c/toO-eiovS'e
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment.
Vertical Up ❑ ❑ Fire 4;1' Isolation
New Installation EI Vertical Down ❑ PIrrigation ❑ Containment by Isolation
Stolen ❑ Horizontal 710 ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
FCIeaned:
1 ❑ Ck#2 ❑ RV
Re -test Results:
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
/� 6
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tigh[
❑ disc . ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
11
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired:
Cleaned`.
!, RPZ
❑ Air Inlet
❑ Air Inlet "
go�g� Air Inlet
�r
Air Inlet
`Q1 Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
pii��CC!! Shutoff Valve #1
1 ❑Leak R Tight
SOV #1 ❑ Open Upon Arrival en At Departure
Backpressure.exists? ❑ YES ❑ NO
Cause
r Shutoff Valve #2
1 ❑ Leak 0 Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture
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 # l 3 B995
o Person Notified: /I fA Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: t 149-/3
?s: I hereby certify that the isolationlShutoff 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
F_ 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 BaekNow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
F"{ (please print))
I Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies o fire line must be registered with the Colorado Division of Fire Safety.