HomeMy WebLinkAbout2469 Forecastle Dr - Special Inspections/Backflow - 12/16/2011CONSULTING • TESTING • SALES • REPAIRS
INSTALLATION • EMERGE,NCCYY SERVICES
,qj'S BG cG Taw Testing g LLC
`Your Cross -Connection Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflowtesting.com E-mail: ajsbft@earthlink.net
Assembly Serial #: 15:1<4 ;2 4 3
Test Date/Time: iP Z6-1/ !I ; Din
Gauge Serial #:
District Required Info:
Tester Certification #: 7GtiI
Date Certification Expires:
Assembly Test Results: ❑ PASS ❑ FAIL
Backf low Prevention Device Test & Maintenance Report 10614
9110 Water District/Authority: Account: Contact Person: -a AC&
Facility Name: .T Contact Phone: -;;-A kwLy"77.7
a Service Address: 4(a c !�M- 4 ��k_ �_L � 14)1 55� e, 61a C
Mailing Address: � /Ne
❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: Ili
p fus Model: ��i5
E1 Size:
�Zd
Type: ❑ RPZ ❑ DC
I PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed:
/ Location on Property: A.aVSt-
❑ Replacement Device
Orientation
Service-
Protection
previous device serial #
Inlet: Outlet:
❑ Domestic
❑ Containment
Vertical Up ❑
El Fire
Isolation
New Installation
r 0 Vertical Down ❑
2Irrigation
❑ Containment by Isolation
❑ Stolen
❑ Horizontal Ja
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ElRv
Cleaned:
O Ck#1 ElCk#2 ❑ RV
Re -test Results:
Tightness Differential
Ti htness Differential
Check Valve #1
RPZ, DC, PVB, SVB
❑ Leak
Tight
1 4-
Ck#1
❑ disc ❑ spring ❑ seat ❑ other
❑ Leak
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired:
Cleaned:.
RPZ
El Air Inlet
El Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
/'�
❑ po pet Elbonnet ❑ other
Shutoff Valve #1
ElLeak 9 Tight
SOV #1 ElOpen Upon Arrival Open At Departure
Backpressure exists? ElYES ❑ NO
❑ Leak Tight
SOV #2 ElO en Upon Arrival ❑ Open At Departure
Shutoff Valve #2
Cause
Assembly Concerns:
T st Procedure:
Comments:
(ohly if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turn-off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # i/ B995
Person Notified: Contacted by:
Turnoff date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolatiorVShutoff 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 procedure shown above required by the Water Districl/Authority shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
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 o a fire line must be registered with the Colorado Division of Fire Safety.