HomeMy WebLinkAbout2856 Exmoor Ln - Special Inspections/Backflow - 01/10/2014CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION•EMERGEN�CYSERVICES '
rA�'S BGiGOW '1 eSt11 g ILC
"Your Cross -Connection Connection"
MO 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303.981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft@earthlink.net
Assembly Serial #: GR �l �e295
Q U c JG)
Test Date/Time: /- /o-14- � I j 47?Ar•1 � �
Gauge Serial #: /Jsncnn r��
District Required Info:
Tester Certification #: Vs -a
Date Certification Expires:
Backflow Prevention Device Test & Maintenance
t:4 -
15381
Water District/Authority: F-/- e ///kt Account:
Contact Person:
Facility Name: RT
Contact Phone:
Service Address: 2 R<to -,u mmr ri h// k .
/d OE-6-25,
Mailing Address: sYAP
1❑ Owner ❑ Manager ❑ Contractor El Other
Contact Person:
Company Name/Title:
Contact Phone:
«
Mailing Address:
Make: /,Lii kltis Model: 72o
A Size:
Type: ❑ RPZ ❑ DC Jl PVB ❑ SVB ❑ Air Gap
AVB ❑ Other Device
Date Installed: Location on Property:
//❑
r,dre;urk JsP
El Replacement Device Orientation
Service Protection
previous device serial # Inlet: Outlet:
❑ Domestic ❑ Containment
J Vertical Up ❑
❑ Fire 'Isolation
New Installation ❑ Vertical Down ❑
E1=1rrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal RP
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Tightness Differential
Ticjhtness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
-;9/ iJ%
❑ 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:
is Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
PVB,
a`
Air Inlet
O/ Air inlet, SVB
i�
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
❑Leak 9 Ti ht
SOV #1 ❑ Open Upon Arrival ❑ Open At Departure
Backpressure exists? El YES ❑ NO
Cause
Shutoff Valve #2
❑.Leak Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At De arture
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 # 14 B995
VQ Person Notified: r /3
Contacted by:
Z Turn off date/time:
Turn on date/time:
Test Kit Make: Mid -West Model: 845
Last Calibration Date:
I hereby certify that the isolatiorVShutoff Valves (SOV Al 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.
�i (please print) AJs Backfiow
(please print)
d Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: -�-
Customer Signature:
Backflow testers who test or repair assemblies on fire line must be registered with the Colorado Division of Fire Safety.