HomeMy WebLinkAbout5733 Big Canyon Dr - Special Inspections/Backflow - 11/01/2013CONSULTING -TESTING -SALES -REPAIRS
INSTALLATION - EMERGENCY SERVICES
Ag'S B"c Tow '1 ESting LLC
"Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfiowtesting.com E-mail: ajsbft@)earthlink.net
Assembly Serial #: -7,53 /a �
TestDate[Time: /)-/-r /ns/�LA^
Gauge Serial #: o �i tnnS
District Required Info:
Tester Certification #: Asa
Date Certification Expires: //-30-/5
Assembly Test Results: P PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
15131
Water District/Authority: Account: Contact Person:
Facility Name: / ),-In a J ,!/owes Contact Phone:
Service Address: 3z &q en
Mailing Address: 574 dPT
U ❑ Owner ❑ Manager ❑.Contractor ❑ Other Contact Person:
22 Company Name/Title: Contact Phone:
O Mailing Address:
Make: FP b ed Model: S' Size: 314
Type: ❑ RPZ O DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: No Sirs ro c-C Aicuxe
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet. ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire lia Isolation
New Installation ❑ Vertical Down ❑ Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal �} ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ Rv
Cleaned:
❑ Ck#1 ❑ ck#2 . ❑ RV
Re -test Results:
Ti htness Differential
Ti htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
n
vc
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
O Leak
RPZ, DC.
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief -Valve
RV
RV, RPZ
❑ Dia hra m ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
fJ
oC t v
❑ poppet ❑ bonnet ❑ other
Shutoff V&IVe #1
1 ❑Leak Tight
I SOV #1 ❑ Open Upon Arrival ❑ Open At De arturackpressure exists? ❑ YES ❑ NO
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Valve #2
❑ Leak Tight
Assembly Concerns:
Terst Procedure:
Comments:
(only if applicable) ,
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
re Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # 13 B995
Person Notified:' AA Contacted by:
Turn off date/time: Turn on date/time:
X� Test Kit Make: Mid -West Model: 845 Last Calibration Date: 6-/9-/3
.;� I hereby certify that the isolatiorUShutoff Valves (SOV #1 and SOV #2) have been returned to the position in which they were found and that the tastiest was done according to
the procedure shown above required by the Water DistdcbAuthodty shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
f' (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies n a fire line must be registered with the Colorado Division of Fire Safety.