HomeMy WebLinkAbout5757 Big Canyon Dr - Special Inspections/Backflow - 06/03/2014CONSULTING -TESTING • S41 ES • REPAIRS
INSTALfATION-EMERGENCY SERVICES
4#
4 j'S Bac�ow TeLting.CLC
'lour Cross -Connection Connection"
1540 27th Sneet, Gmeley, CO 80631
Office 970-352-3090 Cell303-981-7032 Fax 970-356-5794
Websimajsback0omesting.com E-mail: ajsbftCeanhlink.nct
Assembly Serial #:
N 8_2a.37,:;2
Test Datefrime:
l0-3-/4 ( ', 45Pm
Gauge Serial #:
05osW84
District Required Info:
Tester Certification #:
%1S0
Date Certification Expires:
11-30-f5
Backflow Prevention Device Test & Maintenance
b 130(p4-9'
16330
Water District/Authority: P roll,f,'--Lulu d Account: Contact Person:
c Facility Name: 7 r G. rT ! rrrPS Contact Phone:
Service Address: 7 T-7 E7a Ca - y a, b r l ro ll,� s 60SD5a5 -
Q Mailing Address: Saves
V❑ Owner ❑ Manager ❑ Contractor ❑ Other Contact Person:
2 Company Nameffitle: Contact Phone:
j Mailing Address:
Make: Inca Model: 765 Size:
I Type: ❑ RPZ ❑ DC P PVB ❑ SVB ❑ Air Gap ❑ AVB .❑ Other Device
Date Installed: Location on Property: SAP �0.KP
a
E ❑ Replacement Device Orientation Service Protection
w previous device serial # Inlet: Outlet., ❑ Domestic ❑ Containment
R U Vertical Up ❑ ❑ Fire 01solation
New Installation ❑ Vertical Down ❑ Wirrigation ❑ Containment by Isolation
❑ Stolen ❑ Horizontal P% ❑ Other:
Line PSI:
Initial Test Results:
Repaired:
❑ Ck#1 ❑ Ck#2 ❑ RV
Cleaned:
❑ Ck#1 ❑ Ck42 ❑ RV
Re -test Results:
(010
Tightness Differential
Tf htness Differential
Check Valve #1
❑ Leak
/ 4
Ck#1
❑ Leak
` RPZ, DC, PVB, SVB
2 Tight
/ /
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
Check Valve #2
❑ Leak
Ck#2
❑ Leak
RPZ, DC
❑ Tight
❑ disc ❑ spring ❑ seat ❑ other
❑ Tight
m Relief Valve
RV
RV, RPZ
❑ Diaphragm ❑ seat ❑ other
Buffer
Repaired: Cleaned:
RPz
❑ Air Inlet ❑ Air Inlet
c6 Air Inlet
Air Inlet
01 Air inlet, PVB, SVB
❑ poppet ❑ bonnet ❑ other
e
y Shutoff Valve #1
❑Leak Tight
I SOV #1 M O en Upon Arrival 63 O en At De arture
Backpressure exists? ❑YES ❑ NO
F Shutoff Valve #2
❑Leak Tight
SOV #2 Open Upon Arrival C)}'O en Al Departure
Cause
Assembly Concerns:
Test Procedure:
Comments:
(only if applicable)
❑ Incorrect Installation
❑ ABPA ® ASSE
❑ Incorrect use
I Turn off date:
Turn on date:
Turn off time:
Turn on time:
Alarm Company/Fire Department Notified: ❑ Fire suppression contractor certification # (A B995
c Person Notified: 4L Contacted by:
Z. Turn off date/time: Turn on date/time:
Test Kit Make: Mid -West Model: 845 Last Calibration Date:
I hereby certify that the isolation/Shutoff 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 OisMcl/Authodry shown above) and the test readings am true and accumm to the best of my ability.
m (please print) AJS Backilow (please print)
v Testing Company: Testing LLC Phone: 970-352-3090 Customer Name: Phone:
(please print))
Tester Name: AJ Simonson Tester Signature: ti Customer Signature:
Backflow testers who test or repair assemblies oril fire line must be registered with the Colorado Division of Fire Safety.