HomeMy WebLinkAbout432 Bannock St - Special Inspections/Backflow - 08/23/2013CONSULTING - TESTING - SALES - REPAIRS
INSTALLATION - EMERGENCY SERVICES
(A ,17's Ba*ow fisting L,LC
"four Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft@earthlink.net
Assembly Serial #:
Test Datet Time:
Gauge Serial #:
District Required Info:
Tester Certification #:
Date Certification Expires:
Assembly Test Results:
Backflow Prevention Device Test & Maintenance Report
14744
Water DistricVAuthority: f—L ee-) Account:
Contact Person:
Facility Name: z�hC_c,rP �w,.,p�
Contact Phone:
Service Address: 3 2 Rr n n a(� S F �� 1. l! w�
rd F3cx 4
Mailing Address: �; , M e-
ffl6� ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
Mailing Address:
Make: �f.h.- o Model:
76 S Size: 311
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
/'N
Date Installed: Location on Property: &5-ic4P
04 Aed<t)
❑ Replacement Device Orientation
Service Protection
previous device serial # Inlet: Outlet:
❑ Domestic ❑ Containment
Vertical Up ❑
❑Fire _j Isolation
New Installation ❑ Vertical Down ❑
Irrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal (I;k
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
S
Tightness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Ti htness Differential
qfk Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
- Tight
/r
❑ disc ❑ s rin ❑ seat
❑ other
❑Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
C RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Repaired:
Cleaned:
Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
Ila
Air Inlet
Air inlet, PVB, SVB
❑ poppet ❑ bonnet
❑ other
amp Shutoff Valve #1
[OIL ak Ticlht
SOV #1 Open Upon Arrival Open At Departure
Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
❑Leak Tight
SOV #2R Open Upon Arrival Open At De arture
Cause
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 # f B995
Person Notified: AeA
Contacted by:
z Turn off date/time:
Turn on date/time:
Test Kit Make: Mid -West Model: 845
Last Calibration Date: -r fgtz
_ a 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..
(please print) AJs Backfiow
(please print)
Testing Company: Testing LLC, Phone: 970-352-3090 Customer Name: Phone:
Hj (please print))
Tester Name: AJ Simonson Tester Signature:
Customer Signature:
Backflow testers who test or repair assemblies on . ire line must be registered with the Colorado Division of Fire Safety.