HomeMy WebLinkAbout2262 Bar Harbor Dr - Special Inspections/Backflow - 01/24/2014CONSULTING- TESTING• SALES• REPAIRS
INSTALLATION•EMERGEN�CYSERVICES.
Assembly Serial #:
/
.N-77o2%42
-'
.� 's Bac� fisting LLC
Test`A
Gauge Serial #:
Gaugate Serial
/-24- l4 bt IePm
a60S00 b r
.'7ourCross-Connection Connection"
District Required Info:
1540 27th stiret, Greeley, Co 80631
- Tester Certification #:
7,?50
_
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Date Certification Expires:
p
Website: ajsbackflowtesting.com E-mail: ajsbft@eank hlinnet
Assembly Test Results*./W PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
15445
= Water District/Authority: EL- cC)
Account:
Contact Person:
Facility Name: �0,ntey r4P5-
Contact Phone:
Service Address: _72t, 2 -R�
Mailing Address: 4;�tIne
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company NamefTitle:
Contact Phone:
Mailing Address:
Make: Fe6c.y
Model:
;ro5 Size: 3/4
Type: ❑ RPZ ❑ DC PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
114
Date Installed: Location on Property: Ai.
S.r�ea flcvs�
❑ Replacement Device
Orientation
Service Protection
previous device serial #
Inlet: Outlet:
❑ Domestic ❑ Containment
Q
/W Vertical Up ❑
❑ Fire 5�lholation
New Installation
❑ Vertical Down ❑
�,O Irrigation ❑ Containment by Isolation
❑ Stolen
❑ Horizontal )9
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ ck#1 ❑ ckn2 O RV
Cleaned:
❑ ck#1 ❑ ck#z ❑ av
Re -test Results:
Ti htness Differential
Ti htness Differential
Check Valve #1
❑ Leak
/T
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
1!8
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
�.. Air Inlet
/ g
Air Inlet
► Air inlet, PVB, SVB
❑ poppet Elbonnet
❑ other
f3
Shutoff Valve #1
❑ Leak 23 Ti ht
jSOV#1 ❑ Open Upon Arrival ❑ Open At Departure
Backpressure exists? ❑ YES ❑ NO ,
Shutoff Valve #2
1 ❑ Leak R Tight
I SOV #2 ❑ Open Upon Arrival ❑ O en At Departure
Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA (XI ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turnoff time:
Turn on time:
rAlarm Company/Fire Department Notified: ❑ri Fire suppression contractor certification # /4B995
Person Notified: AAw Contacted by:
1Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
1 hereby certify that the isolationAShutoffValves (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 Backflow (please print)
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 o a fire line must be registered with the Colorado Division of Fire Safety.