HomeMy WebLinkAbout2602 Bar Harbor Dr - Special Inspections/Backflow - 03/30/2010CONSULTING TESTING SALES REPAIRS
INSTALLATION EMERGENCYSERVICES
Ag s Bad�ffow 11'esting LLC
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1 40 27 h S G I} CO 80611
Offi )70 352 3090 C II 303 981 7032 F )70 3565794
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Assembly Serial # H 57U416
Test DatefFime 3130110 S SaAa
Gauge Serial # b CSoi7,9�
District Required Info
Tester Certification # 7950
Date Certification Expires
Assembly Test Results JQ PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
U 6004
Water District/Authority it L CAccount Contact Person
5iv q
Facility Name Contact Phone
2v?-- 5�11-57'77
0 Service Address .2lao L fur l -tbev- r r--4 <ofl h s Co 80$-74
Q Mailing Addrei 4*�7 L.,,c R 14Yz I r e CCU ScS14-
WOwner ❑ Manager ❑ Contractor ❑ Other Contact Person
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M Company Name/Title Contact Phone
Mailing Address
Make Model 7& S� Size 3/.4
Type ❑ RPZ ❑ DC 1� PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
>` Date Installed Location on Property S S de eAkc-,o-K-e
B
E ❑ Replacement Device Orientation Service
Protection
rwn previous device serial # Inlet Outlet ❑ Domestic
❑ Containment
N
Q ❑ Vertical Up ❑ ❑Fire
Isolation
fj4-New Installation 25 Vertical Down ❑ �CIrngation
❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other
Line PSI
Initial Test Results
Repaired
❑ Ck#t ❑ Ck#2 ❑ RV
Cleaned
❑ Ck#t ❑ Ck#2 ❑ RV
Re test Results
d
TI htness Differential
TI htness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ DC PVB SVB
Tight
(�
-T
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
V RPZ DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
m Relief Valve
RV
RV RPZ
❑ Diaphragm ❑ seat ❑ other
a Buffer
Repaired
Cleaned
(U RPZ
ElAir Inlet
ElAir Inlet
I Q
Air Inlet
ca Air Inlet
of A it PVB SVB
`�
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1 ❑ Leak 10 T Ohl SOV #1 ❑ Open Upon Arrival ❑ Open At De arture Backpressure exists? El YES ❑ NO
y
Shutoff Valve #2 ❑ Leak Ti ht SOV #2 ❑ Open Upon Arrival ElOpen At De arture Cause
Assembly Concerns T st 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 El Fire suppression contractor certification # )D B995
a)
Person Notified f t} Contacted by
o
z Turn off date/time Turn on date/time
Y Test Kit Make Mid West Model 845 Last Calibration Date
S�3 by
th by ert fy th t th solat on/Sh t N Val (SOV # t d SOV #2) h e bee t ed to th p to wh h they we f nd a d th
t th last test w doe d rig to
th p d e sh w b e eq d by the W t D st ct/A th ty how b e) a d th tested g a e t d c ate to th best of my b i ty
ai (please print) AJs Backtlow (please print)
y Testing Company Teshnp LLC Phone 970 352 3090 C tourer Name
Phone
12 (please print)) `
Tester Name AJ Simonson Tester Signature Customer Signature
Backflow testers who test or repair assemblies on a fire line must be registered with the Colorado Division of Fire Safety