HomeMy WebLinkAbout5609 Big Canyon Dr - Special Inspections/Backflow - 09/07/2013" cONSUMW•TESTING•S4LES•REPAIRS' JJ
INSTALLA17ON•EMERGENCYSEROCES Assembly Serial #: u %\n �3-�72 1
I� ' Testing f1C Test Date/Time:. G-7�I 3 G,'azAvvx
%.�'S BGiCGauge Serial #: c!�, 5:, S, -, RCY
'Tour cre55-connectwnConnection" District Required Info:
154027th street, Gmeley, CO 80631 Tester Certification#: "`99i�
Office 970-352-3090 Cell 303-981-7032 Fax970-356-5794 Date Certification Expires:
Website: ajsback9te owsting.com E-mail: ajsblt(gearthlink.net _ p
Assembly Test Results: PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report 14900
Water District/Authority:
Account:
Contact Person:
Facility Name: l /an d 4>1nc
s
Contact Phone:
Service Address: E—,(,c�G
,1 �,� >-4 In 114
a Mailing Address: :To Ate
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
2. Company Name/Title:
Contact Phone:
01 Mailing Address:
Make: �P(06o
Model:
%65 Size:
Type: .❑ RPZ ❑ DC t PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: St
5' cornef--,)4: Lx,; c2
E ❑ Replacement Device
Orientation
Service Protection
Iprevious device serial #
Inlet: Outlet:
❑ Domestic ❑ Containment
R Vertical Up ❑
❑ Fire Isolation
I� New Installation
❑ Vertical Down ❑
Irrigation /❑ Containment by Isolation .
❑ Stolen
❑ Horizontal l" 7
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
TI htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
/
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
S Tight
c�,,
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
�►. RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑. Tight
W Relief Valve
RV
RV, RPZ
❑.Dia hra m ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
Air Inlet
❑ Air Inlet "
ai� Air Inlet
Oj Air inlet, PVB, SVB
�tfl
❑ poppet ❑ bonnet
❑ other
G
Shutoff Valve #1
❑Leak Ti ht .
SOV #1. CQO en Upon Arrival 0 Open At De arture Backpressure exists_ ? ❑ YES ❑ NO
�. Shutoff Valve #2
❑ Leak Tight
SOV #2 1340 en Upon Arrival PO en At Departure Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable) .
❑ Incorrect Installation'
❑ ABPA (M ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
�+ Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 15 B995
9 Person Notified: Contacted by:
z Turn off date/time: Turn on date/time:
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff 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.
.d. (please print) AJs Backflow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t (please print))
Tester Name: AJ Simonson Tester Signature: / Customer Signature:
Backflow testers who test or repair assemblies on -fi're line must be registered with the Colorado Division of Fire Safety.