HomeMy WebLinkAbout816 Brookedge Dr - Special Inspections/Backflow - 08/15/2011FROM :COMPONBJT SYSTEMS FOR TURF FAX NO. :482 8832 Aug. 15 2011 08:03PM P1
el I0139-1
Test DateTme:
COMPONENT SYSTEMS LLC Gauge Serial #: 09 91996
Backfiow Testing Services District Required Info. Permit: 81100991
Tester Certification #: ASSE 6403
970-472-9773 Date Certification Expries: 3/10/2012
Assembly Test Results: KPASS ❑ FAIL
RETAIN A COPY OF THIS REPORT FOR THREE YEARS
Facility Name:
Service Address:
Mailing Address:
Contact Phone: 720-301-
ligi
;_ "Owner L i Manager LI Contractor U Other koontaet verson:
;Company Name/Title: Shadow Creek Homes Contact Phone:
�Mailing Address: 2861 W. 120th Ave., Suite 240, Westminster CO 80236
Type: LJ RPz ❑ DC J&PVB 7., 5v6 ❑ Air Gap (-1 AVs ❑ other Device
ft wi
Dade Installed: Location on Property: trray.9.
!jPf'❑ Replacement Device Orientation Service Protection
previous device serial # Inlet Outlet ❑ Domestic j j Containment
OF n Vertical UP ❑ L_j Fre
rt PERMIT M , J Isolation
lJ New Installation ❑Vertical Down ❑ r': Irrigation —
;;s;'; _ Containment by Isolation
-i l; ❑ SMlen ❑ Horizontal ❑ ❑ Wier:
"} Line PSI:
Initial Test Results:
Repaired:
Cleaned:
Retest Results
❑ Ck//I ❑ Ck#2 I7 RV
❑ Ck#i ❑ Ck#2 ❑ RV
Ti htness Differential
T, htness Differential
Check alve #1
Leak
Ck#1
n Leak
:,
1 i t
n
❑disc rin seat other
❑ Tight
: :.Check
Leak
C 2
L� Leak
4u ';=;': ` �; •
(� Tight
i•.•
❑disc ❑spring ❑ seat other:
j] Tight
Relief Valve
RV
_
n 0iaphragm I. I seat n other.
:Buffer
Repaired:
Cleaned:
❑ Air Inlet
❑ Air Inlet
Air Inlet
=A r ;t ;r; !>�i . S'wE
,J
. 7
Air Inlet
❑ poppet ❑ bonnet other
Shutoff Valve #1
r..TLeak Tit ht
SOV 91: L Open upon Arrival L Open At Departure
BackpresSure
Cause
exists? YES NO
.` Shutoff Valve #2 1
Lj Leak LaTight
SOV 02 , Open upon Arrival Open At Departure
i Assembly Concerns:
'b9r
Test Procedure:
romments,
.:
7'r
ASPA ASSE
❑
iI ®W �{%v/ 1 / r/-"/rl �i B(r(% D W� /
n Incorrect Installation
q
rr_
`- Incorrect Use
• Turn oft date:
Turn on date:
�}� i.g Q � pe Gt �Bri ay �' wA
}
�R!:Tum off time:
Turn on time:
% LO ag.0 7i G B �
•e, c4
Alarm Company/Fire Department Notified LJ Fire suppression contractor certification #
B1007
Person Notified:
Contacted by:
Turn off date/time:
Turn on dateJtime:
Test Kit Make:
Midwest Model: 845-5 Last Calibration Date:
i hereby certify that the isclavordShworr Vahoes (sov xi eno so az) ngve O?en retumed to Me POS001) in which trey were rpimd and lha..he last 2S ties done- acoOrdmg to the
`
procedure shown above required Oy the water pistricl/A44norrty shown above)
n.
(please Print)
(please print)
' :
Testing Company:
Component SyS Phone.472-9773 C Name:
Phone
(please prinr)
Tester Name: Charlotte Harms Tester Signature:irstomer Signature:
ite - water suppIter Yellow - 'ester Pink - owner