HomeMy WebLinkAbout2303 Thoreau Dr - Special Inspections/Backflow - 01/24/2014CONSUL77MG • TESTING • SALES • REPAIRS ...
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-
Assembly Serial #:
-. . .
S -
. j'S Bac Tow Testing �C
Test
Gaugate/Time:
Gauge Serial #:
2�-14 v;¢ttAr,
D5c55cof39
"Your Cross -Connection Connection"
District Required Info:
-
154027thSueet,Greeley, Co80631
Tester Certification #:
- -7r50
.0ffice970352-3090 Cell 303-981-7032 Faz970-35&5794
Date Certification Expires:
p
il--3v-1s
' Website: ajsbackilowtesting.com E-mail: ajsbft®eanhlink.net
Assembly Test Results:
)9PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report
15434
Water District/Authority: 2!�LCO
Account:
Contact Person:
_. Facility Name: _1.r—nev
Contact Phone:
Service Address:
Mailing Address: Sarre
VI ❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
2 Company Name/Title:
Contact Phone:
0�
Mailing Address:
Make:
Model: '7a1f>A
Size:
Type: ❑ RPZ ❑ DC W'PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property: AA
T.Le d4:-"5jE'
E
❑ Replacement Device
Orientation
Service
Protection
I.
previous device serial #
Inlet: Outlet:
❑ Domestic ❑
Containment
a'
I
F Vertical Up ❑
❑ Fire 9-Isolation
f New Installation
❑ Vertical Down ❑
Prrigation ❑
Containment by Isolation
❑ Stolen
❑ Horizontal 9�0
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Re -test Results:
Tightness Differential
Tightness Differential
❑ ck#i ❑ Ck#2 ❑ RV
❑ ck#t ❑ ck#2 El
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
9 Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
�► RPZ; DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
cc Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
otj Air Inlet
Z r4
Air Inlet
.t) Air inlet, PVB, SVB
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
1 ❑ Leak 52 Tight
ISOV#1 ❑ Open Upon Arrival ❑ Open At Departure
Backpressure
Cause
exists? ❑ YES ❑ NO
�. Shutoff Valve #2
1. ❑ Leak Tight
I SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
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 # /4 B995
c Person Notified: / Contacted by:
Z Turn off date/time: Turn on date/time:
r
Y Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolatiorVShutoff 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 Backf/ow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
t " (please print))
Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblie � n a fire line must be registered with the Colorado Division of Fire Safety.