HomeMy WebLinkAbout420 Noquet Ct - Special Inspections/Backflow - 08/23/2013CONSULTING • TESTING •SALES • REPAIRS
INSTALLATION • EMERGENCY SERVICES
9[3's Bac Tow fisting LLC
Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackfcwtesling.com E-mail: ajsbft@earthlink.net
Assembly Serial #: f-1 'l5s5�
Test Date/Time: fR-23 /3 )0,Z"1/�Y�I
Gauge Serial #: �itov„534
District Required Info:
Tester Certification #: 7czso
Date Certification Expires: /i_ 30-/S'
W PASS ❑
Backflow Prevention Device Test & Maintenance Report
Vvb,�00�
14769
4- Water District/Authority: 4' L c o Account: Contact Person:
K Facility Name: Contact Phone:
Service Address: !44 o I -)C4UP 4- c-1 + /l.k r� e-d R-)f_:7 It
Mailing Address: Tram
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: lr� hno Model: 7i S Size: Z/d
Type: ❑ RPZ ❑ DC PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
/�E
Date Installed: Location on Property: _(Al, S Aec}r 6,35 P
❑ Replacement Device Orientation Service Protection
previous device serial If Inlet: Outlet: ❑ Domestic ❑ Containment
Vertical Up ❑ ❑ Fire Isolation
;0 New Installation ❑ Vertical Down ❑ PIrrigation ❑ 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
cpl r
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
l RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
cBuffer
❑ Diaphragm ❑ seat ❑ other
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
I
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
1 ❑ Leak bg Ti ht
SOV #1 ®Open Upon Arrival 2 Open At Departure Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2
1 ❑ Leak Tight
I SOV #2 Open Upon Arrival 0 Open At Departure Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA M ASSE
❑ Incorrect Use
t Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # /3 B995
ya Person Notified: AA Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: .5 /9-/3
I hereby certify that the isolatiorVShutolf 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 DistrictlAuthonty 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:
(please print))
Tester Name: AJ Simonson Tester Signature: h Customer Signature:
Backflow testers who test or repair assemblies gina fire fine must be registered with the Colorado Division of Fire Safety.