HomeMy WebLinkAbout964 Snowy Plain Rd - Special Inspections/Backflow - 07/15/2011Assembly,Serial #:
Test Date/Time:
COMPONENT SYSTEMS LLC Gauge Serial #: 09091 96
Backflow Testing Services District Required Info: Permit:
Tester Certification #: ASSE 6403
970-472-9773 Date Certification Expries: 3/10/2012
Assembly Test Results: PASS ❑ FAIL
RETAIN A COPY OF THIS REPORT FOR THREE YEARS
..: Water District /Authority: FC/Love Account: Contact Person: Mike
5 Facility Name: Contact Phone: 720-301-1333
:.c°,:t Service Address: 964 Snowy Plain Rd.
q Mailing Address:
Owner ❑ Manager F Contractor ❑ Other Contact Person:
Company Name/Title: Shadow Creek Homes Contact Phone:
Mailing Address: 2861 W. 120th Ave., Suite 240, Westminster, CO 80235
i= Type: ❑ RPZ
❑ DC PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed:
Location on Property: A",
S'�,Ja'1 Lori
'Ex ❑ Replacement Device
Orientation
Service
Protection
.Q:
tV). previous device serial #
Inlet: Outlet:
Domestic
❑ Containment
Q;
❑ Vertical Up ❑
❑ Fire
❑Isolation
;.: ❑ New Installation
PERMIT #: ❑Vertical Down ❑
❑Irrigation
containment by Isolation
❑ Stolen
❑ Horizontal ❑
❑ Other:
Line PSI: ,
Initial Test Results:
Repaired:
❑ ck#I ❑ Ck#2 ❑ RV
Cleaned:
❑ ck#I ❑ ck#z ❑ Rv
Re -test Results
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Z
Ck#1
❑ Leak
f
fight
❑disc ❑spring El ❑other.
❑Tight
Check Valve #2
ELeak
Ck#2
❑ Leak
a►
❑ Tight
❑ disc ❑ spring El ❑other:
❑ Tight
=4 Relief Valve
RV
❑ Diaphragm ❑ seat ❑ other:
Buffer
Repaired:
Cleaned:
❑ Air Inlet
❑ Air Inlet
Air Inlet
L J n
Air Inlet
1'.11SE!
poppet ❑ bonnet El other:
Shutoff Valve #1
Leak Tight
SOV #1: Open Upon Arrival L Open At Departure
Backpressure
Cause
exists? YES Lj NO
N1 Shutoff Valve #2
. 0.
Leak i Tight
SOV #2: Open Upon Arrival Open At Departure
Assembly Concerns:
Test Procedure:
Comments:
AX GY 1LY►'!!�-ri
❑ incorrect Installation
ABPA ❑ASSE
-� C
❑ Incorrect Use
. Tum off date:
Turn on date:
Turn off time:
Turn on time:
& Alarm Company/Fire Department Notified LJ Fire suppression contractor certification #
B1007
Person Notified:
Contacted by:
0 Turn off date/time:
Turn on date/time:
Y Test Kit Make:
Midwest Model: 845-5 Last Calibration Date:
/
!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
t'$
procedure shown above required b the Water District/Authorit shown above
p 9 Y Y )
m' (please print)
(please print)
� , Testing Company:
Component Sys Phone 472-9773 Customer Name:
Phone
(please print)
Tester Name: Charlotte Harms Tester Signature: Customer Signature:
►te - Water Supplier Yellow - Tester Pink - Owner