HomeMy WebLinkAbout2263 Marshfield Ln - Special Inspections/Backflow - 04/07/2014}v C
COWSUM 9•rt:SM-SM-R£PMIRB
I46IALAIYON•611191169 CYSolVOS
An' Bac6KOW Testing LLC
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154027th saw, Greeley, CO RMI
Office 970-352-3090 Cell 303-981-702 Fax 970.356.57%
WeMae: ej>bacldtoateidngoom &nail: ajrbh6attMinkaet
60
Assembly Serial #: 4
Test DateTme: '
Gauge Serial #:
District Required Info:
Tester Certification #: 74��
Date. Certification Expires:
Backflow Prevention Device Test & Maintenance Report
15710
Water District/Authority: Account: Contact Person:
Facility Name: ney &9me5 Contact Phone:
Service Address: �?— ��Tll L,,
Mailing Address: 22 m a
❑ Owner O Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Tltle: Contact Phone:
Mailing Address:
ke; kJ. ,1ti5 Model: Size: 3/�J
M[01
e: ❑ RPZ Cl DC P PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property:
eplacement Device Orientation Service Protection
ious device serial # Inlet: Outlet' ❑ Domestic O Containment
Vertical Up ❑ ❑ Fire ,-4fflsolavon
ew installation ❑ Vertical Down ❑ �nigation ❑ Containment by Isolation
tolen ❑ Horizontal 'qX ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ Rv
Cleaned:
O Ck#1 ❑ Ck#2 O RV
Re -test Results:
IA
Tightness Differential
Ti htness Differential
Check Valve #1
O Leak
Ck#1
❑Leak
RPZ DC, PVB Sve
Ti ht
, !'ri
❑ disc ❑ rin ❑ seat ❑ other
❑ Tight
Check Valve #2
O Leak
Ck#2
❑Leak
RPZ
O T ht
❑ disc ❑ rin O seat ❑ other
❑ Tight .
Relief Valve
AV
y
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPZ
❑ Air Inlet ❑ Air Inlet
Air Inlet
Air Inlet
Air Inlet, PVB, SVB
O
❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1
❑ Leak wilaht ISOV#1
O0panUPonArrlvW ❑ O en At Departure
Backpressure exists? OYES ❑ NO
I Cause
Shutoff Valve #2
❑ Leak
'right I
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Assembly Concerns:
Tbst Procedure:
Comments:
(onty i/applicable)
O Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn off time:
Turn on time:
fi
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # Z:4 B995
Person Notified: AIA Contacted. by:,
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby cerhly that the isokawn/Sh" Valves (SOV #1 and SOV 40 ham been ralumed to Me position in which they were burid and that the last rest was done according to
Me Procedure shown abOW required by Me Water DlstrkVAuthorlty shown above) the
and rest rea*w are true and accurate to the best or my awiry.'
(please print) AJs BAcidlow (please print)
Testing Company: Testing LLC Phone: 970-W2-W90 Custo er Name: Phone:
(please print))
=1 Tester Name: AJ Simonson Tester Signature: Customer Signature:
Backflow testers who test or repair assemblies ono fire line must be registered with the Colorado Division of Fire Safety.