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CONSULTING TESTING SALES REPAIRS
INSTALLATION EMERGENCYSERVICES
A J s Bac)f(ow fisting LLC
Y C C ct C t
1540 27 h S G I ) CO 80631
Offi 970 352 3090 C II 303 981 7032 F 970 356 5794
W b t j b kfl Wt t g m E m I I bf C hi k t
Assembly Serial # H 5 mtCCC�77S
Test Date/Time "/ /,0 fo rol A"
Gauge Serial # 6ss
District Required Info
Tester Certification # 79-ein
Date Certification Expires 11J3nl17
❑ FAIL
Backf low Prevention Device Test & Maintenance Report
H2 8417
Water District/Authority tG -C, Account Contact Person SA K
c Facility Name e P Contact Phone �;<q/ 4777
0Service Addressyaloc2 A.-I-SGn �4 �ol/I,s Co 805.?4
Q Mailing Address <am(f
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person
V
2 Company NamefTitle Contact Phone
Mailing Address
Make e 6 co Model 765 Size 14
Type ❑RPZ ❑ DC CrPVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
P Date Installed Location on Property iv 5,wec>47Ao►triie
a
E ❑ Replacement Device Orientation Service Protection
y previous device serial # Inlet Outlet ❑ Domestic ❑ Containment
N
Q � Vertical Up El ❑Fire Isolation
New Installation ❑ Vertical Down ❑ 5orrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal tO ❑ Other
Line PSI
Initial Test Results
Repaired
Cleaned
Re test Results
o
Tightness Differential
❑ C1k#1 ❑ Ck#2 ❑ RV
❑ Ck#1 ❑ Ck#2 ❑ RV
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ DC PVB SVB
Tight
g
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV RPZ
❑ Diaphragm ❑ seat ❑ other
Repaired
Cleaned
s Buffer
RPZ
❑ Air Inlet
❑ Air Inlet
S
Air Inlet
.a Air Inlet
of A I t PVB SVB
❑ poppet ❑ bonnet ❑ other
C
y Shutoff Valve #1 ❑ Leak bPFight I SOV #1 IYOoen Upon Arrival Wpen At De arture Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2 1 ❑ Leak 2 ht SOV #2 ❑ Open Upon A al ❑ Open At Departure Cause
Assembly Concerns T st Procedure Comments
(only If applicable)
❑ Incorrect Installation ❑ ABPA Z ASSE
❑ Incorrect Use
Turnoff date Turn on date
Turn off time Turn on time
Alarm Company/Fire Department Notified ❑ Fire suppression contractor certification # ,in B995
Person Notified IVA Contacted by
c
Z Turn off date/time Turn on date/time
Y Test Kit Make Mid West Model 845 Last Calibration Date -S ./
I he eby rt fy that the solat orVSh t IT V I s (SOV # l a d SOV #2) h been et ed t th p t wh ch they w f d d th t th I It t w d d g t
the p oc Of h w bo a eq Of by th W t D st WA th ty h w bo e) d th t t d gs a e t ea d t t the best of my ab i ty
N (please print) AJs Backf/ow (please print)
y Testing Company Testing LLC Phone 970 352 3090 Customer Name Phone
(please print))
Tester Name AJ Simonson Tester Signature 4 Customer Signature
Backflow testers who test or repair assemblies on 9fire line must be registered with the Colorado Division of Fire Safety