HomeMy WebLinkAbout2620 Bar Harbor Dr - Special Inspections/Backflow - 05/03/2010�..w�i^-�.+^+T..im ais�w{ty�rr a+--._�_....n,_ __.-row. . � � r . .._ �_^i. __ ^y•• r_
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CONSULTING TESTING SALES REPAIRS
INSTALLATION EMERGENCY SERVICES
Assembly Serial #
�sf 'Ba4 IOW '1 Est1n1g LEC
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Test e real #
Gauge Serial #
)our Criss Conn ction Cmn ction
District Required Info
U40 27th St eel Greeles Co 80631
Tester Certification #
Office 970 352 3090 Cell 303 981 7032 Fax 970 356 D794
Date Certification EX p Tres
Rebsne aj bickflo tesun com E mad alsbftCearthl nk net
Assembly Test Results
Backflow Prevention Device Test & Maintenance Report
L
C.X
N° 8118
Water District/Authority Account Contact Person 51ziK
Ate-:
'o Facility Name �z.r f ems Contact Phone 703 .5V/--i�77
0 Service Address �Yirter,/.�S fd �a5o74
Q Mailing Address Some
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person
U
M Company Name/Title Contact Phone
Mailing Address
Make rP bYa Model %lo'� Size 3%4
Type ❑ RPZ ❑ DC f VB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
S Sc�P t1�itOyS('
a Date Installed Location on Property
73
E ❑ Replacement Device Orientation Service Protection
y previous device serial # Inlet Outlet ❑ Domestic ❑ Containment
a)
Q X Vertical Up ❑ ❑ Fire Isolation
❑ New Installation ❑ Vertical Down ❑ �trrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ❑ Other
Line PSI
Initial Test Results
Repaired
Cleaned
Re test Results
Ti htness Differential
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#) ❑ Ck#2 ❑ RV
Tightness Differential
Che k Valve #1
❑ Leak
Q
Ck#1
❑ Leak
RPZ DC PVB^SVB
Pd Tight
1I U
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
v RPZ DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired
Cleaned
s Buffer
Co RPZ
N.
ElAir Inlet
❑ Air Inlet
Air Inlet
ca Air Inlet
0) Air inlet PVB SVB
❑ poppet ❑ bonnet ❑ other
C
Shutoff Valve #1
1 ❑Leak Tight
SOV #1 Open Upon Arrival Xopen At Departure
Backpressure exists ❑YES ❑ NO
H
Shutoff Valve #2
Cause
❑Leak Tight
SOV #2 O en U on Arrival O en 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
a) Alarm Company/Fire Department Notified ElFire suppression contractor certification # la B995
Person Notified A/14 Contacted by
c
z Turn off date/time Turn on date/time
Y Test Kit Make Mid West Model 845 Last Calibration Date i —r 0
1 hereby certify that the isolation/Shutoff 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 DistricbAuthonty shown above) and the test readings are true and accurate to the best of my ability
a) (please print) AJs BackfloW (please print)
y Testing Company Testm_q LLC Phone 970 352 3090 Customer Name Phone
(please pnnt)) <
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