HomeMy WebLinkAbout2751 Denver Dr - Special Inspections/Backflow - 03/26/2014CONSULTING• TESTING• SALES• REPAIRS
A Lk INSTALLATION • EMERGENCY SERVICES
%I's Bac Tow Testing LLC
"Your Cmss-Connection Connection"
1540 27th Stint. Greeley, CO 80631
Office 970-352-3090 Cell 303.981-7032 - Fax 970-356-5794
Website: ajsbackflowtesting.mm E-mail: ajsbft@earthlink.net
Assembly Serial #: T 17-14 91
Test DatelTime: 3-7&-14 — `a;o0m
Gauge Serial #: O.S�coo¢iq
District Required Info:
Tester Certification #: xi�fl
Date Certification Expires: /1,;�.7 /4�
Backflow Prevention Device Test & Maintenance Report
15659
Water District/Authority: F+ lo)1 q- S
Account:
Contact Person:
Facility Name: T rneu AM-5
Contact Phone:
Service Address: .27s 111P_„
eo//flea 1 'n
R05.2-J
Mailing Address: ante
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
a Company Name/Title:
Contact Phone:
Mailing Address:
Make: //it)) k\t5
Model:
?,2oxl Size:
Type: ❑ RPZ ❑ DC PVB
❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
/P&
Date Installed: Location on Property: s" S,:Ip6-PkCV5P
❑ Replacement Device
Orientation
Service Protection
previous device serial #
Inlet: Outlet:
❑ Domestic ❑ Containment
J Vertical Up ❑
❑ Fire /O Isolation
New Installation
❑ Vertical Down ❑
PIrrigation ❑ Containment by Isolation
❑ Stolen
❑ Horizontal �.
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 El RV
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
3D
Ti htness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#I
❑ Leak
RPZ, DC, PVB, SVB
Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
a Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
Air Inlet
Air inlet, PVB, SVB
ar
❑ poppet ❑ bonnet
❑ other
Shutoff Valve #1
1❑ Leak (Zj'Ti ht
SOV #1 ❑ Open Upon Arrival ❑ open At Departure
Backpressure exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
1 ❑ Leak 8 Tight
SOV #2 ❑ Open Upon Arrival ❑ Open At Departure
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect Use
Turn off date:
Turn on date:
Turnoff time:
Turn on time:
Alarm Company/Fire Department Notified:. ❑ ' Fire suppression contractor certification # 14 B995
Person Notified: Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date: < /S/3
I hereby certify that the isolatior✓ShutoN Valves (SOV # r 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 DistrictlAuthonty shown above) and the test readings are true and accurate to the best of my ability.
(please print) AJs Backflow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Cus Omer Name: Phone:
F- (please print))
Tester Name: AJ Simonson Tester Signature:. Customer Signature:
Backflow testers who test or repair assemblies on a ire line must be registered with the Colorado Division of Fire Safety.