HomeMy WebLinkAbout2421 Sunbury Ln - Special Inspections/Backflow - 04/07/2014coesturaas • resnas • s4tEs • arvuas'
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IV Ms s Bac6II&wTe'Snna LLC
*your crolf-conn&WM conic crion^
1540 27th Street. Greeley, CO 80631
Office 970.352-3090 Ce11303.981.7Q12 Fas970.3563794
Wetelta ajdackdowandog.com 11-mail: *bft0ce Ink.W
Assembly Serial #: T 1'77 IDS
Test Dat&Mme: 4-,7•-r4 12: o&b»
Gauge Serial #: Sc�F44
District Required Info:
Tester Certification #: -7q scv
Date Certification Expires:
Assembly Test Results: J@ PASS ❑ FAIL
Backflow Prevention Device Test & Maintenance Report
15737
Water Distriet/Authorfty: nLcv Account:
Contact Person:
Facility Name: r
Contact Phone:
Service Address: -;ZA-2 I r refs
la S:>c�
Mailing Address: Same
❑ Owner ❑ Manager ❑ Contractor ❑ Other
Contact Person:
Company Name/Title:
Contact Phone:
Mailing Address:
Model:
7aoA- Size:
ype: ❑ RPZ ❑ DC ,21 PVB ❑ SVB ❑ Air Gap
❑ AVB ❑ Other Device
Date Installed: Location on Property:
lMake:
❑ Replacement Device Orientation
Service Protection
previous device serial 9 Inlet: Outlet•
❑ Domestic ❑ Containment
Vertical up ❑
❑ Fire � Isolation
PNew Installation ❑ Vertical Down ❑
RIrrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal ,lam❑
Other. .
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#t ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#t ❑ Ck#2 ❑ RV
Re -test Results:
Ti htness Diifferentlal
Ti htness Differential
Check Valve #1
❑ Leak
f' 8
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
0 Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Check Valve #2
❑ teak
Ck#2
❑ Leak
'
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat
❑ other
❑ Tight
Relief Valve
RV
RV, RPZ
❑ Dia hra m ❑ seat
❑ other
Buffer
Repaired:,
Cleaned:
RPZ
❑ Air Inlet
❑ Air Inlet
Air Inlet
'
1
Air Inlet
Air Inlet, PVB, SVB
/ /
❑ poppet ❑ bonnet
❑ other
Shuitoff.Valve #1
❑ Leak Tight
ISOV#1
❑ O an U on Arrival ❑ Open At Departure
Backpressure exists?. O YES ❑ NO
Cause
Shutoff Valve #2
❑Leak Tight
I SOV
#2 ❑ Open Upon Arrival ❑ Open At Departure
Assembly Concerns:'rest
Procedure:
Comments:
(only i1 appAcable)
❑ Incorrect Installation
❑ ABPA M ASSE
❑ Incorrect Use
Tllm off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # y4 B995
Person Notified: All
Contacted by:
Turn off dateMme:
Turn on dateltime:
Test Kit Make: Mid -West Model: Ba
Last Calibration Date: s /Fr73
=v
I hereby certity that the isaa#on1shutcB Valves.(SOV #t anti SOV #2) have been returned to &a position in which they were found and that Me last test was done according to
the procedure shown above required by the Water ownct(Audiority shown above) and the test readings are true and accurate to the best of my abifitfc
(please print) AJS BackNow
(please print)
Testing Company: Testing LLC Phone: 970-352-3090 Customer
ame: Phone:
(please print))
Tester Name: Ad Simonson Tester Signature:
_ Customer Signature:
Backflow testers who test or repair assemblies on a re line must be registered with the Colorado Division of Fire Safety.