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CONSULTING TESTING SALES REPAIRS
INSTALLATION EMERGENCYSERVICES
Aj s Bac)f(ow fisting LLC
Y C C t C r
1540 27 h S G I y CO 80C31
Ofh 970 352 3090 C II 303 981 7032 F 970 356 5794
W b j b kfl w @ m E mad i bf C hl k
Assembly Serial #
Test DatefTime
Gauge Serial #
District Required Info
Tester Certification #
Date Certification Expires
Assembly Test Results
Backflow Prevention Device Test & Maintenance Report
M
7s_56� I M® 8296
IN]
Water District/Authority Le-d
Account
Contact Person
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oo Facility Name ,.;cxNAe
t
Contact Phone
303- 5'777
0 Service Address �(0 5 of-c�s-i lc NO- to// k 5 elep �4
a Mailing Address Sa..ne
❑ Owner ❑ Manager ❑ Contractor
❑ Other
Contact Person
V
2 Company NamefTitle
O
Contact Phone
Mailing Address
Make
Model
7(� $ Size
3 4
Type ❑ RPZ ❑ DC PCPVB
❑SVB ❑ Air Gap
❑ AVB ❑ Other Device
>` Date Installed
Location on Property Al
a
E ❑ Replacement Device
Orientation
Service
Protection
0 previous device serial #
Inlet Outlet
❑ Domestic
El Containment
N
Q
,2P Vertical Up ❑
El Fire
19 Isolation
New Installation
❑ Vertical Down ❑
,irrigation
❑ Containment by Isolation
Stolen
❑ Horizontal Tr
❑ Other
Line PSI
Initial Test Results
Repaired
Cleaned
Re test Results
Tightness Differential
Tightness Differential
�G10
❑ Ck#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ DC PVB SVB
A Tight
/
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
m Relief Valve
RV
N RV RPZ
❑ Diaphragm ❑ seat
❑ other
s Buffer
Repaired
Cleaned
RPZ
❑ Air Inlet
❑ Air Inlet
ca Air Inlet
S
Air Inlet
0) A I t PVB SVB
❑ poppet ❑ bonnet
❑ other
C
y Shutoff Valve #1
❑ Leak WTcIht
I SOV #1 4 Open Upon Art al 111 Open At Departure
Backp essu e e sts? ❑ YES ❑ NO
❑ Leak T1 ht
I SOV #2JrOpen Upon Arrival Open At Depa ture
Shutoff Valve #2
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 t me
cD Alarm Company/Fire Department Notified ❑ Fire suppression contractor certification # 1OB995
c Person Notified 104 Contacted by
z Turn off date/time Turn on date/time
Y Test Kit Make Mid West Model 845 Last Calibration Date S/r /o
I he eby cert fy th t th I t n/Sh t ft V I (SOV # 1 d SOV #2) ha a bee et ed to the pos t o wh h th y w t d a d th t the last test was done acco Of g to
th p Of h w b q Of by th W t D t VA th ty sh w bo e) a d the test ead gs a e t e a d acc rate to th b t t my b I ty
a`, (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 /�//� Customer Signature
Backflow testers who test or repair assemblies onla fire line must be registered with the Colorado Division of Fire Safety