HomeMy WebLinkAbout5715 Big Canyon Dr - Special Inspections/Backflow - 11/01/2013CONSULTING -TESTING -SALES -REPAIRS
INSTALLATION - EMERGENCY SERVICES
,7'S B"c Tow '12Sti11A LE
"Your Cmss-Connectfort Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970.356-5794
Website: ajsbackflowtesting.com E-mail: ajsbfigearthlink.net
Assembly Serial #: P/�Z��LL_
Test DaterTime: a-ti4 /n(inAym
Gauge Serial#: aSn5e70S9
District Required Info:
Tester Certification #: 7yTa
Date Certification Expires:
Assembly Test Results: 'PP PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
15130.
Water District/Authority: Account: Contact Person:
Facility Name: Contact Phone:
Service Address: rr4 t^� �Z_ t'a//it2s
Mailing Address: Somv
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
o-" Company Name/Title: Contact Phone:
e
Mailing Address:
Make: Model: Size: 4q
i Type: ElRPZ O DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
/-®
? Date Installed: Location on Property: S4 amide oS {l(h_/CP
r� _
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet. ElDomestic ❑ Containment
Vertical Up ❑ ❑ Fire 9 Isolation
�❑
New Installation Vertical Down Rlrrigation ❑ 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:
7
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
;- RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
e Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired: Cleaned:
Buffer
fog RPZ
6
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air Inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1 -1
❑ Leak ja Tight
I SOV #.1 ❑ Open Upon Arrival ❑ Open At De arture Backpressure exists? ❑ YES ❑ NO
SOV #2 ElOpen Upon Arrival ❑ Open At Departure Cause
IN Shutoff Valve #2
❑ Leak
Tight
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 # 13 B995
Person Notified: AA Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: 5--43=1?
��. I hereby certify that the isolatiorvShutoNValves (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 DistricNAuthodty shown above) and the test readings are true and accurate to the best or my ability.
(please print) AJS Backflow (please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print)) _
fl Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies o a fire line must be registered with the Colorado Division of Fire Safety.