HomeMy WebLinkAbout2627 Forecastle Dr - Special Inspections/Backflow - 06/02/2010—. r 2 P4w10 %-)-1 pip ,/"`.ITN, ,�r w •� I:r-, M....-. " 11, !L l lji r,ta,%.4'L -w^t ,-"`Jw a -4 ,�:n. , .. ....... - Y
CONSULTING TESTING SALES REPAIRS
INSTALLATION EMERGENCYSERWCES
Ag s Backf(ow Tsting -ELC
Yau C C t Cn h
140 27 h S G I y CO 80631
Offi 970 352 3090 C II 103 981 7032 F 970 356 57)4
W b 3 b kfl w 6 m E m l i bf C It k
Assembly Serial # /' S 7S 97L o
Test DatelTime/Z/i o /Z TM
Gauge Serial # aSos4-=0m
District Required Info
Tester Certification # 71r So
Date Certification Expires ///gam/ 1Z
Assembly Test Results)?] PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
Water District/Authority 4;:�o Lno
Account
Contact Person
SA4 y
o Facility Name �«�nev
PS
Contact Phone
3v3-S�/ i7�7
0 Service Address �6V7 Gi-l45`�IC Dr �+ /e/I �s GoBczSa�i
a Mailing Address 54rAt
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person
U
2 Company Name/Title
Contact Phone
O
Mailing Address
Make re-
Model
7&5 Size -3�4
Type ❑ RPZ ❑ DC PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
>` Date Installed Location on Property N Sip/tOt7SP
Z
E ❑ Replacement Device
Orientation
Service
Protection
w previous device serial #
Inlet Outlet
❑ Domestic
❑ Containment
to
Q
Vertical Up ❑
❑ Fire
isolation
New Installation
❑ Vertical Down ❑
Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal ,K
❑ Other
Line PSI
Initial Test Results
Repaired
Cleaned
Re test Results
Tightness Differential
Tightness Differential
Elckat ❑ ckn2 ❑ RV
❑ ck#t ❑ cktt2 ❑ RV
Check Valve #1
❑ Leak
o
Ck#1
❑ Leak
RPZ DC PVB SVB
Tight
C7
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
N RV RPZ
❑ Diaphragm ❑ seat
❑ other
s Buffer
Repaired
Cleaned
0 RPZ
❑ Air Inlet
❑ Air Inlet
,a Air Inlet
/
Air Inlet
C A I t PVB SVB
❑ poppet ❑ bonnet
❑ othe
y Shutoff Valve #1
❑ Leak Tight
SOV #1 ❑ Open Upon Arrival i9 Open At Departure
Backpressure exists9 ❑ YES ❑ NO
Shutoff Valve #2
1 ❑ Leak XT ght
I SOV #2 ❑ Open Upon Arr val 00pen At Departure
Cause
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 # /OB995
c Person Notified
Contacted by
Z Turn off date/time
Turn on date/time
Y Test Kit Make Mid West Model 845 Last Calibration Date /2 O
I he by t ly that the solat on/Sh toff V I (SOV # 1 a d SOV #2) he a bee at ad to the pos t wh ch they we a to d a d that the last test was do a acco d g t
the p d h w b q d by th W t D t
VA tho ty h w bo e) a d th t t d g t d t t th b t t my b i ty
M (please print) AJs Backflow
(please print)
y Testing Company Testing LLC Phone 970 352 3090 Customer Name Phone
(please print))
Tester Name AJ Simonson Tester Signature f/
Customer Signature
Backflow testers who test or repair assemblies o
a fire line must be registered with the Colorado Division of Fire Safety