HomeMy WebLinkAbout2557 Maple Hill Dr - Special Inspections/Backflow - 04/17/201400011SO irts•7EaravSUES•iilEii6iS
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154027th Shod, Gtoeloy, CO M31
01eee970.352-3M Cell=.981a072 Fa■970-35&719e
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Assembly Serial #: :' I -n- 9 Ste` -I
Test DateMme. 4,17-14 q;zefd T
Gauge Serial #: o Se.5,& a%
District Required Info:
Tester Certification #: 74fSkp
Date Certification Expires: %f340�]s
Backflow Prevention Device Test & Maintenance Report
15772
Water District/Authority- A Account:
Contact Person:
Facility Name: liai
Contact Phone:
Service address: _ a?s S -r ;l(
Mailing Address: s1r rote
❑ Owner 0 Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
Mailing Address:
ME
ake: Model:
2WA- Size:
pe: El RPZ ❑ DC )FPVB C] SVB 0 Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property
e
Replaceerd Device rien o
m
IE3
Service Protection_.�bta
device sert� # Inlet.• Outlet
❑ Domcm
estic inent
Vertical Up ❑
❑ Fire Isolation
New Installation ❑ VQrtical Down ❑
stolen Q Horizontal
Pirrigation ❑ Containment by laot0on
❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ ckal ❑ Cka2 El Rv
Cleaned:
Q Cks1 Q CId#2 ❑ RV
Re -test Results:
Ti htness Differential
TI htness Differential
Check Valve #1
RM Dc. Ma svB
❑ Leah
0 Tight
1.4
Ck#1
Q also d M22 ❑ seat
❑ other
❑ Leak
❑ Tight
Check Valve #2
❑ Leah
Ck#2
❑ Leak
RPZ, tic
❑ light
❑ dac ❑ wring ❑ seat
❑ gM
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat
❑ other
Buffer
Repaired:
Cleaned:
RPZ
❑ Air inlet
❑ Air Inlet
Air Inlet
Airtdet, Pv9, SVS
n
oCa0
Air Inlet
1 p Po Cl bonnet
❑ other
Shutoff Valve #1
1 ❑ Leak 2 Tlaht
IS0V#1O
U Affj3_W
Q0PenA1Qeoaftm
Badcpfmvr9 exists? ❑ YES ❑ NO
Cause
Shutoff Valve #2
1 ❑ Leak R Tiaht
I SOV
#2 ❑ Open Upon Arrival ❑ Ooen At DeVerture
Assembly Concerns:
(may Nawk:able)
Ust Procedure:
ments•
❑ Incorrect installation
❑ ABPA M ASSE
❑ Inowact Use
'film oft date:
Tum on date:
Ibm oft time:
Ibm on title:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification #
Person Notified:
Tarn oft dateltime:
Contacted by:
Tllm on datettime:
Test Kit Make: Mid -West _ Model: 845
Last Calibration Date: -f-Ws'3
l ftr9by carwy drat the fspleao vshufoB Uh- es (SOV Of and SOV A2) ham been reharrad to ale Doom is ankh ales ware found and a+at ft fast teat was done aawitl ng b
the Praicsdtrre shown above required by the Water OaWWAualvdty shown above) and ale test readaw are true and aerxrrata to the beat of fly ablllr$
(please pant) AJs BACJdtow (Please print)
Testing Company: Te9dn9 LLC Phone: A70452-3M Customer Name: Pam:
(please print)) e
'� ? Tester Name: AJ Simonson Tester Signature:
Customer Signature:
Backflow testers who test or repair assemblies o fire line must be registered with the Colorado Division of Fire Safety.
900/000'd L090 9NILS31 MOldN9Ve ry
09L9996OL13I 9Z:VL V1.0Z/LL/V0