HomeMy WebLinkAbout2226 Bar Harbor Dr - Special Inspections/Backflow - 05/22/2014coNSuLnNG*TESTING•SALES *REPAIRS
INSTALLATION • EMERGENCY SERVICES
A,9's Bac Tow ?Jesting LLC
"Your Cra55-00nnecdon Connection"
1540 27th Street, Greeley, CO 80631
Office 970-352-3090 Cell 303-981-7032 Fax 970-356-5794
Website: ajsbackflovesting.com E-mail: ajsbft@earthlink.net
Assembly Serial #:
Test DatefTime:
Gauge Serial It:
District Required Info:
Tester Certification #:
Date Certification Exoires:
Backflow Prevention Device Test & Maintenance
75'So
s
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Water District/Authority: "F/-(-,^3 Account: Contact Person:
Facility Name: 6\() rrvm Contact Phone:
Service Address: 27� /� M il� FG ��//,tis Inr✓9
_
Mailing Add ess: Same
❑ Owner �❑ Manager ❑ Contractor ❑ Other Contact Person:
Company Name/Title: Contact Phone:
Mailing Address:
Make: (UJ Model: 712n 4 Size:
Type: ❑ RPZ ❑ DC ;R3 PVB ❑ SVB ❑ Air Gap ❑ AVB ❑ Other Device
Date Installed: Location on Property: A !z 4 rnGlAco
❑ Replacement Device Orientation Service Protection
previous device serial # Inlet: Outlet: ❑ Domestic ❑ Containment
,'..
a' `3 Vertical Up ❑ ❑ Fire Swi Isolation
.,.i New Installation ❑ Vertical Down El Irrigation ❑Containment by Isolation
❑ Stolen ❑ Horizontal ,2 ❑ Other:
1 -,,Line PSI:
Initial Test Results:
Repaired:
El Ck#1 ❑ Ck#2 ❑ Rv
Cleaned:
❑ Ck#1 ❑ Ck#2 ❑ RV
Re -test Results:
Cod
Tightness Differential
Tightness Differential
Check Valve #1
❑ Leak
Ck#1
❑ Leak
RPZ, DC, PVB, SVB
2 Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
iv RPZ, Do
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Relief Valve RV
RV, RPZ ❑ Diaphragm ❑ seat ❑ other
c Buffer Repaired: Cleaned:
RPZ ❑ Air Inlet ❑ Air Inlet
Air Inlet n Air Inlet
U
0) Air inlet, PVB, SVB r ❑ poppet ❑ bonnet ❑ other
Shutoff Valve #1 ❑ Leak 21 Tight SOV #1 ❑ Open Upon Arrival cQ Open At Departure Backpressure exists? ❑ YES ❑ NO
Shutoff Valve #2 1 ❑ Leak Tight I SOV #2 ❑ Open Upon Arrival ❑ Open At Departure Cause
Assembly Concerns: Test Procedure: Comments:
(only if applicable)
' ❑ Incorrect Installation ❑ ABPA ® ASSE -
❑ Incorrect Use
Turnoff date: Turn on date:
Turn off time: Turn on time:
Alarm Company/Fire Department Notified: ❑J1 Fire suppression contractor certification # l4 B995
Person Notified: (1M Contacted by:
Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:. 115-/4
I hereby certify that the JaclationSh.toff Valves (SOV #1 and SOV #2) have been returned to the position in which they were round and that the last test was done according to
the procedure shown above required by the Water DistricVAuthodty shown above) and the test readings are true and accurate to the best or my ability.
M (please print) AJs BeCMlow (please print)
y Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
k' (please print))
Tester Name: AJ Simonson Tester Signature: // Customer Signature:
Backflow testers who test or repair assemblies ort,61fire line must be registered with the Colorado Division of Fire Safety.