HomeMy WebLinkAbout2314 Bar Harbor Dr - Special Inspections/Backflow - 11/27/20136111SULTING-TESTING-SALES-REPAIRS
INSTALLATION-EMERGENCYSERVICES Assembly Serial #: 1 Ro 14 totem ..
Test Date/Time: // T � al ioayim
9L .s-B"c Tow Sting .EC Gauge Serial #: ,0cbScao89
Your Cross -Connection Connection" District Required Info:
f I 27th Street, Greeley, CO 80631 Tester Certification #: 72Sc
Office 970-352-3090 Cell 303-981-7032 Fax970-356-5794 Date Certification Expires:
Website: ajsbackttowtmting.com E-mail: ajsbft@eanhlink.net p
Assembly Test Results: PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report ( 15231
Water District/Authority: PI-c 0 Account: Contact Person:
Facility Name: �' n Contact Phone:
Service Address: as 1.4 &.� r-Am— P' - e�o//eks to a__ 4
Mailing Address: sQ alto
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
S Company Name/Title: Contact Phone:
Mailing Address:
Make: A),� V, vX-5 Model ;7Z,2, Size: 3/4
Type: ❑ RPZ ❑ DC 121-'PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: d-V� %005c9
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire Wsolation
New Installation ❑ Vertical Down ❑ PIrrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Ti htness Differential
Ti htness Differential
00
❑ Ck#1 ❑ Ck#2 ❑ Rv
❑ Ck#1 - ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
// /
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
/t p
❑ disc ❑ spring ❑ 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:
c Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
o� Air Inlet
2
Air Inlet
Air inlet, PVB, SVB
-
❑ poppet ❑bonnet ❑ other
Shutoff Valve #1
❑ Leak C2 Tight
jSOV#I ❑ Open Upon Arrival ❑ Open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
❑ Leak P9 Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Assembly Concerns:
T st Procedure:
Comments:
(only, i/ 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 # K B995
o Person Notified: t-A Contacted by:
2 Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff Valves (SOV 1111 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 DistriebAuthority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs BackNow (please print)
"A Testing Company: Testing LLC Phone: 970-352-3090 Cust met Name: Phone:
I" (please print))
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.